Obstetrics

Question 1

Miscarriage

Answer 1

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

Question 2

Missed miscarriage 
Threatened miscarriage 
Inevitable miscarriage 
Incomplete miscarriage 
Complete miscarriage 
Anembryonic pregnancy

Answer 2

o Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred.
o Threatened miscarriage – vaginal bleeding with a closed cervix (closed os) and a fetus that is alive. Risk to pregnancy
o Inevitable miscarriage – vaginal bleeding with an open cervix (products sited at open os). Pregnancy can’t be saved
o Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage (closed os). Part of pregnancy is lost
o Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus (closed os)
o Anembryonic pregnancy – a gestational sac is present but contains no embryo

Question 3

Miscarriage signs/symptoms

Answer 3

positive urine pregnancy test
• Bleeding primary symptom (more than cramping) and varied amount
• “period type cramps” are described
• Passed products may be brought in
• Cervical shock (products at cervical os and dilating it): Cramps, nausea/vomiting, sweating, fainting.

Question 4

Miscarriage Ix

Answer 4

• Speculum exam to assess stage of miscarriage: is the os closed?
  • A transvaginal ultrasound scan
  o Mean gestational sac diameter
  o Fetal pole and crown-rump length
  o Fetal heartbeat
  • When a fetal heartbeat is visible, the pregnancy is considered viable. A fetal heartbeat is expected once the crown-rump length is 7mm or more.
  • When the crown-rump length is less than 7mm, without a fetal heartbeat, the scan is repeated after at least one week to ensure a heartbeat develops. When there is a crown-rump length of 7mm or more, without a fetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.
  • A fetal pole is expected once the mean gestational sac diameter is 25mm or more. When there is a mean gestational sac diameter of 25mm or more, without a fetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.
  • To confirm: Early foetal demise or non continuing pregnancy (pregnancy in-situ, no heartbeat: mean sac diameter > 25 mm, foetal pole > 7mm)

Question 5

Miscarriage Mx

Answer 5

<6 weeks (no pain or risk of complicatons)
- expectant Mx: repeat preg test 7-10 days after miscarriage

> 6 weeks
- Expectant management: offered first-line for women without risk factors for heavy bleeding or infection.
• 1 – 2 weeks are given to allow the miscarriage to occur spontaneously.
• A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete.

Medical Management: Misoprostol
• is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.
vaginal suppository or an oral dose. S/E heavy bleeding, pain, vomiting and diarrhoea

Surgical management: Misoprostol and 500 units of Anti-D Manual vacuum aspiration (<10 weeks gestation) or electric vacuum aspiration

Question 6

Incomplete miscarriage Mx

Answer 6

o Medical management (misoprostol)

o Surgical management (evacuation of retained products of conception)

Question 7

Recurrent miscarriage and Mx

Answer 7

• 3 or more pregnancy losses
• Independent risk factors – age and previous miscarriages
• Antiphospholipid syndrome (LAC, ACA, B2glycoproteinI)
• Thrombophilia link being researched in a national trial (factor V leiden and prothrombin gene mutations, Protein C, free protein S and antithrombin)

Mx
• Use of low dose aspirin and daily fragmin injections after confirmation of viable IUP in evidence of anti-phospholipid syndrome
• Use of progesterone pessary in unexplained cases if age >35 years and 2 or more losses

Question 8

Ectopic pregnancy risk factors

Answer 8

• Previous ectopic pregnancy
• Previous pelvic inflammatory disease e.g. female upper genital tract, including the womb, fallopian tubes and ovaries.
• Previous surgery to the fallopian tubes
• Intrauterine devices (coils)
• Older age
• Smoking: kill of microvilli in the tube
• Infertility – more likely to be damaged
• Inferility treatment – IVF (egg in fluid and injected straight in – risk it will go up)

Question 9

Ectopic signs/symptoms

Answer 9

• Missed period
• Constant lower abdominal pain in the right or left iliac fossa (pain>bleeding)
• Vaginal bleeding
• Lower abdominal or pelvic tenderness
• Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
• Dizziness or syncope (blood loss)
• Shoulder tip pain (peritonitis)

Question 10

Ectopic pregnancy Ix

Answer 10

FBC, Group and save and bhCG

transvaginal ultrasound scan: blob sign. Moves seperately to the ovary

Features that may also indicate an ectopic pregnancy are:
o An empty uterus
o Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)

Question 11

Pregnancy of unknown location

Answer 11

• positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan/amenorrhea
• Serum human chorionic gonadotropin (hCG) can be tracked over time to help monitor a pregnancy of unknown location
o A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy. A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l.
o A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review.
o A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete

Question 12

Ectopic pregnancy Mx

Answer 12

Expectant management:
- unruptured, adnexal mass <35mm, no HR, no pain, HCG<1500 IU/L

Medical management: Methotrexate

• same as above but HCG <5000 IU/L
• dont get pregnant for 6 months
• Vaginal bleeding, N&V, abdo pain and stomatitis

Surgical management:

• Pain, adnexal masss >35mm, visible HR and HCG >5000 IU/L
• Laparoscopic salpingectomy (removal of tube)
• Laparoscopic salpingotomy (cut in tube)
• Anti- Rd 500 IU

Question 13

Molar Pregnancy (hydatiform)

Answer 13

gestational trophoblastic disease which grows as a mass characterised by swollen chorionic villi. Categorized as partial moles or complete moles

• complete mole occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form. Overgrowth of placental tissue
• partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time or 1 sperm cell (reduplicating DNA). The new cell now has three sets of chromosomes (it is a haploid cell 69XXY triploid). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form
• Complete hydatidiform moles have a higher risk of developing into choriocarcinoma (a malignant tumour of trophoblast) than partial moles.

Question 14

Molar pregnancy signs/symptoms

Answer 14

o More severe morning sickness
o Vaginal bleeding: spotting/bleeding
o Increased enlargement of the uterus
o Abnormally high hCG
o Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
o Early onset pre-eclampsia
o Rare cases: shortness of breath due to embolization to the lungs or seizures (mets to brain)

Question 15

Molar pregnancy Ix

Answer 15

USS: snowstorm appearance

T4, T3 and hCG

Question 16

Molar pregnancy Mx

Answer 16

• Surgical evacuation of the uterus to remove the mole and products of conception need to be sent for histological examination to confirm a molar pregnancy.
• In higher gestation where fetus is present in partial mole medical management can be undertaken
• Patients should be referred to the gestational trophoblastic disease centre for management and follow up.
• The hCG levels are monitored until they return to normal. Occasionally the mole can metastasise, and the patient may require systemic chemotherapy.

Question 17

Implantation bleeding

Answer 17

• Occurs when the fertilised egg implants in the endometrial lining
• Timing is about 10 days post ovulation
• Bleeding is light brownish and self-limiting
• Soon signs of pregnancy emerge e.g. breast tenderness and morning sickness

Question 18

Chorionic haematoma

Answer 18

• Pooling of blood between endometrium and the embryo due to separation: sub chorionic

• Bleeding, cramping, threatened miscarriage
• Symptoms and course follow size and perpetuation
• Large haematomas may be source of infection, irritability (causing cramping) and miscarriage
• Usually self-limiting and resolve
• Reassurance important but surveillance should remain

Question 19

Hyperemesis gravidarum (HG)

Answer 19

Nausea and vomiting are normal during early pregnancy. Symptoms usually start from 4 – 7 weeks, are worst around 10 – 12 weeks and resolve by 16 – 20 weeks.
• hCG is thought to be responsible. Nausea and vomiting are more severe in molar pregnancies and multiple pregnancies due to the higher hCG levels. It also tends to be worse in the first pregnancy and overweight or obese women.
• Hyperemesis gravidarum is the severe form of nausea and vomiting in pregnancy

Question 20

Hyperemesis gravidarum (HG) signs/symptoms

Answer 20

o More than 5 % weight loss compared with before pregnancy
o Dehydration
o Electrolyte imbalance
• Ketosis and nutritional disturbance
• Weight loss, altered liver function
• Signs of malnutrition
• Emotional instability, anxiety. Severe cases can cause mental health issues e.g. depression

Question 21

HG Mx

Answer 21

• Rehydration IVI, electrolyte replacement

Anti-emetic:

1st: Cyclizine, prochlorperazine
2nd: metoclopramide

•	Thiamine supplement 50mg tds / pabrinex 
•	NG feeding and TPN
•	Ranitidine and omeprazole: acid reflux
•	Prednisolone 40mg/day 
•	Thromboprophylaxis
TOP

Question 22

Termination of Pregnancy documentation

Answer 22

• Certified on HSA1 form (“Certificate A”) - 2 doctors sign (green form): for A to E
• Two ‘emergency’ Clauses (F and G) - one doctor signs (HSA2)
• Clause C: An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of:
o The pregnant woman
o Existing children of the family

•Clause E: An abortion can be performed at any time during the pregnancy if (no gestational limit):
o Continuing the pregnancy is likely to risk the life of the woman
o Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
o There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

Question 23

TOP Ix

Answer 23

Clinical
o Estimated by LMP +/- date of +ve UPT
o Palpable uterus (> 12 wks)

Ultrasound
o Abdominal or transvaginal (< 6wks)

Question 24

Medical abortion

Answer 24

Mifepristone 200mg (blocks action of progesterone, halting the pregnancy and relaxing cervix)

Misoprostol 800mcg (prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions)

<12 weeks: self admister mife/miso at home
- 2nd dose misoprostol if >10 weeks
>12 weeks: inpatient - Repeated doses of PV misoprostol: 800mcg PV then 400mcg 3-hourly PV/PO/SL (up to 4)

if >10 weeks: anti D
VTE high risk: LMWH

Question 25

Surgical Abortion Mx

Answer 25

misoprostol or osmotic dilators (soften and dilate cervix prior) ``` o < 14wks  Electric vacuum aspiration (GA)  Manual vacuum aspiration (up to 10wks; LA) o >14wks  Dilatation and evacuation ```

Question 26

After care for TOP

Answer 26

Preg test 2/3 weeks after abortion Immediate provision of Long-Acting Reversible Contraception (LARC): post abortion sepsis Hormonal methods

Question 27

Infertility

Answer 27

• Infertility defined as inability to conceive after 12 months regular intercourse without contraception Causes • Sperm problems (30%) • Ovulation problems (25%): oligomenorrhea and amenorrhea • Tubal problems (15%) • Uterine problems (10%) • Unexplained (20%) • 40% of infertile couples have a mix of male and female causes.

Question 28

Infertility Ix

Answer 28

Body mass index (BMI) • Chlamydia screening • Semen analysis • Rubella immunity Serum progesterone on day 21 of the cycle Anti-Mullerian hormone (related to inhibin and activin) Thyroid function tests If amenorrhoeic/cycle longer than 42days o Serum LH and FSH on day 2 to 5 of the cycle  High FSH suggests poor ovarian reserve  High LH may suggest polycystic ovarian syndrome (PCOS). Prolactin Ultrasound pelvis and transvaginal Hysterosalpingogram • Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis Hysteroscopy

Question 29

Infertility Mx

Answer 29

Lifestyle - Clomifene citrate (stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH) - Alternatively: Letrozole (stimulate ovulation) - Gonadotropins injections - Laparoscopic Ovarian drilling •Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS) Mx Tubal factors: Tubal cannulation during a hysterosalpingogram (proximal lesions), Laparoscopy to remove adhesions or endometriosis and In vitro fertilisation (IVF) Mx Uterine: correct polyps, adhesions or structural abnormalities

Question 30

Management of Sperm Problems

Answer 30

* Surgical sperm retrieval is used when there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen. * A needle and syringe is used to collect sperm directly from the epididymis through the scrotum. * Surgical correction of an obstruction in the vas deferens may restore male fertility. * Intra-uterine insemination involves collecting and separating out high-quality sperm, then injecting them directly into the uterus to give them the best chance of success. It is unclear whether this is any better than normal intercourse. * Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg. These fertilised eggs become embryos, and are injected into the uterus of the woman. This is useful when there are significant motility issues, a very low sperm count and other issues with the sperm. * Donor insemination with sperm from a donor is another option for male factor infertility.

Question 31

IVF cycle

Answer 31

* Suppressing the natural menstrual cycle * Ovarian stimulation * Oocyte collection * Insemination / intracytoplasmic sperm injection (ICSI) * Embryo culture * Embryo transfer

Question 32

UTI pregnancy Mx

Answer 32

Non-pregnant Women: • Urine culture should be sent if age>65 or haematuria is present • Trimethoprim or nitrofurantoin for 3 days Symptomatic Pregnant Women: • Urine culture done • Nitrofurantoin (1st and 2nd trimester), Trimethoprim 3rd trimester Asymptomatic Pregnant Women: • Urine culture should be done at 1st antenatal visit • High risk of progressing to acute pyelonephritis • Immediate course of Nitrofurantoin (avoid near term pregnancy), amoxicillin or cefalexin for 7 days should be started • Urine culture after treatment, for test of cure.

Question 33

``` Gravida (G) Primigravida Multigravida Para (P) Nulliparous Primiparous Multiparous ```

Answer 33

* Gravida (G) is the total number of pregnancies a woman has had * Primigravida refers to a patient that is pregnant for the first time * Multigravida refers to a patient that is pregnant for at least the second time * Para (P) refers to the number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was alive or stillborn * Nulliparous (“nullip”) refers to a patient that has never given birth after 24 weeks gestation * Primiparous: patient that has given birth after 24 weeks gestation once before * Multiparous: patient that has given birth after 24 weeks gestation two or more times

Question 34

Trimesters

Answer 34

* The first trimester is from the start of pregnancy until 12 weeks gestation. * The second trimester is from 13 weeks until 26 weeks gestation. * The third trimester is from 27 weeks gestation until birth.

Question 35

Additional milestones for antenatal care

Answer 35

* Anti-D injections in rhesus negative women (at 28 and 34 weeks) * Ultrasound scan at 32 weeks for women with placenta praevia on the anomaly scan * Serial growth scans are offered to women at increased risk of fetal growth restriction

Question 36

Pregnancy lifestyle advice

Answer 36

Folic acid 400mcg from before pregnancy to 12 weeks • Individuals with diabetes, on anti-epileptic medications and those with BMI>30, individuals with a previous pregnancy affected by a neural tube defect, or mothers who have a personal history or have a partner with a history of neural tube defect will need to take 5mg daily from 12 weeks. • Take vitamin D supplement (10 mcg or 400 IU daily) • only an extra 250-300 calories needed to support a pregnancy especially in the last trimester. Avoid vitamin A supplements and eating liver or pate Don’t drink alcohol Don’t smoke Avoid unpasteurised dairy or blue cheese ( • risk of listeriosis) • Avoid undercooked or raw poultry (risk of salmonella) • Continue moderate exercise but avoid contact sports • Sex is safe • Flying increases the risk of venous thromboembolism (VTE) • Place car seatbelts above and below the bump (not across it)

Question 37

Alcohol in pregnancy

Answer 37

o Miscarriage o Small for dates o Preterm delivery o Fetal alcohol syndrome: microcephaly, thin upper lip, smooth flat philtrum, short palpebral fissure, learning disability and behaviour disability

Question 38

Management of substance abuse in antenatal care

Answer 38

* Consider methadone programme – to avoid chaotic lifestyle * Child protection and social work referral * Smear history – put measures in place to ensure the woman gets involved with a screening programme * Breastfeeding education * Labour plan regarding analgesia and labour ward delivery * Early IV access * Postnatal contraception plan

Question 39

Booking clinic

Answer 39

10-12 weeks gestation • A history will be taken including medical, surgical, drug, social and family history. • Additional details such as date of the last menstrual period, whether the pregnancy was planned and ethnicity of parents [to identify risk factors for developing haemoglobinopathies like sickle cell anaemia or beta thalassemia]. • An obstetric history will also be taken including previous pregnancy, mode of delivery, previous miscarriages or terminations. • Blood group, antibodies and rhesus D status • Full blood count for anaemia • Screening for thalassaemia (all women) and sickle cell disease (women at higher risk) • Patients are also offered screening for infectious diseases, by testing antibodies for: o HIV o Hepatitis B o Syphilis Other: BMI, Urine (protein and bacteria), BP

Question 40

Booking clinic risk assessment for additional appointments

Answer 40

o Rhesus negative (book anti-D prophylaxis) o Gestational diabetes (book oral glucose tolerance test) o Fetal growth restriction (book additional growth scans) o Venous thromboembolism (provide prophylactic LMWH if high risk) o Pre-eclampsia (provide aspirin if high risk)

Question 41

Screening for fetal abnormality

Answer 41

18-20+6weeks gestation for conditions below and placenta site - anencephaly, spina bifida, cleft lip, gastroschisis, exemphalos, congential cardiac

Question 42

Downs syndrome screening

Answer 42

Combined test (11 and 13+6 weeks gestation) • Ultrasound measures nuchal translucency o A normal value for nuchal translucency is ≤ 3.5mm. o Down’s syndrome > nuchal thickness 6mm •Maternal blood tests: o beta-HCG – a higher result indicates a greater risk o Pregnancy‑associated plasma protein‑A (PAPPA) – a lower result indicates a greater risk Triple test (14-20 weeks gestation) o Beta-HCG – a higher result indicates greater risk o Alpha-fetoprotein (AFP) – a lower result indicates a greater risk o Serum oestriol (female sex hormone) – a lower result indicates a greater risk ``` Quadruple test (15-16 weeks) - same as triple + A higher inhibin-A indicates a greater risk. ```

Question 43

Definitive testing for downs syndrome

Answer 43

o Chorionic villus sampling (CVS) involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 12-15 weeks). <2% risk of miscarriage o Amniocentesis involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe. This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample. Usually after 15 weeks <1% risk of miscarriage

Question 44

Non-Invasive Prenatal Testing

Answer 44

* Cell free fetal DNA (cffDNA) * The blood will contain fragments of DNA, some of which will come from the placental tissue and represent the fetal DNA. * These fragments can be analysed to detect conditions such as Down’s. * NIPT is not a definitive test, but it does give a very good indication of whether the fetus is affected.

Question 45

Rhesus Incompatibility

Answer 45

* Individuals who lack these antigens are termed rhesus negative while those who have the antigen are rhesus positive. * Women that are rhesus-D positive do not need any additional treatment during pregnancy. * blood from the baby will find a way into the mother’s bloodstream. * When this happens, the baby’s red blood cells display the rhesus-D antigen. * The mother’s immune system will recognise this rhesus-D antigen as foreign, and produce antibodies to the rhesus-D antigen. The mother has then become sensitised to rhesus-D antigens. * When mothers are first exposed to the rhesus antigen, they form IgM antibodies which are too big to cross the placenta and harm the current fetus. However, in future pregnancies when the mother is exposed to the same antigen from the fetus’ red blood cells, the body forms IgG antibodies which are smaller and can cross the placenta to harm the fetus leading to haemolytic disease of the newborn. * If that fetus is rhesus-D positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack them, causing the destruction of the red blood cells (haemolysis). * The red blood cell destruction caused by antibodies from the mother is called haemolytic disease of the newborn.

Question 46

Rhesus Incompatibility Mx

Answer 46

IM anti-D injections to rhesus-D negative women. Anti-D injections are given routinely on two occasions: o 28 weeks gestation & 34 weeks o Birth (if the baby’s blood group is found to be rhesus-positive) sensitisation (give anti-D within 72 hours) may occur, such as: o Placental abruption o Any abdominal trauma (from road traffic accidents for example) o Amniocentesis or chorionic villus sampling o External cephalic version o Intra-uterine surgery/transfusion o Fetal death o Vaginal bleeding from 12weeks o Surgical management of miscarriage at <12 weeks o Evacuation of retained products of conception and molar pregnancy o Termination of pregnancy o Ectopic pregnancy o Delivery (if baby is rhesus-D positive)

Question 47

Kleinhauer test

Answer 47

done at 20 weeks * The Kleihauer test involves adding acid to a sample of the mother’s blood. Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth. * Therefore, fetal haemoglobin persists in response to the added acid, while the mothers haemoglobin is destroyed. The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated

Question 48

fetal anaemia

Answer 48

* There are other causes of fetal anaemia such as parvovirus and other congenital infection such as cytomegalovirus, syphilis, toxoplasmosis. * In addition, haemoglobinopathies (thalassaemia, sickle cell), feto-maternal haemorrhage and monochorionic twin complications are other causes of fetal anaemia.

Question 49

fetal anaemia Mx

Answer 49

fetal blood sampling and in utero transfusion via the umbilical vein under ultrasound guidance. • When the anaemia is extremely severe, the fetus can experience heart failure and develop a condition called hydrops fetalis. • Hydrops fetalis is a condition where there is abnormal accumulation of fluid in 2 or more compartments and manifests as ascites, pleural effusion, skin oedema, pericardial effusion • Hydrops fetalis is a late and poor sign of feta anaemia and if untreated could result in death. • If at more than 32 weeks, the fetus will be delivered for ex-utero transfusion.

Question 50

Epilepsy and pregnancy

Answer 50

• Ideally, epilepsy should be controlled with a single lowest dose anti-epileptic drug before becoming pregnant. o Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medication in pregnancy o Sodium valproate is avoided as it causes neural tube defects and developmental delay (be careful with child bearing women) o Phenytoin is avoided as it causes cleft lip and palate

Question 51

Epilepsy – maternal/fetal risks

Answer 51

``` • Risks from maternal seizure o Maternal abdominal trauma – FMH (fetal maternal haemorrhage) o PPROM (premature rupture of membranes) o Preterm birth o Hypoxia/acidosis • Fetal risks o Major congenital malformations o Minor malformations o Adverse perinatal outcomes o Long-term developmental effects o Haemorrhagic disease of the newborn o Risk of childhood epilepsy ```

Question 52

Maternal epilepsy Mx

Answer 52

* Left lateral tilt * IV lorazepam / diazepam * PR diazepam / buccal midazolam * IV Phenytoin * May need to expedite delivery by CS * If no history of epilepsy - MgSO4

Question 53

pregnancy drugs yes and no

Answer 53

``` • YES: o Steroids o Azathioprine o Sulfasalazine o Hydroxychloroquine o Aspirin o (Etanercept / Infliximab / Adalimumab) o (Rituximab) • NO: o NSAIDs (>32 weeks) o Cyclophosphamide o Methotrexate o Chlorambucil o Gold o Penicillamine o MMF o Leflunamide ```

Question 54

Antiphospholipid syndrome

Answer 54

* An acquired thrombophilia with variable presentation and severity * Antiphospholipid antibodies (aPL) - autoantibodies that react with the phospholipid component of the cell membrane * Arterial / venous thrombosis * Recurrent early pregnancy loss * Late pregnancy loss - usually preceded by FGR * Placental abruption * Severe early onset pre-eclampsia (PET): before 32 weeks * Severe early onset Fetal Growth Restriction (FGR) Laboratory: X2 / >6 weeks apart o IgM / IgG aCL (medium / high titre) o LA

Question 55

APS Mx

Answer 55

• No thrombosis / adverse pregnancy outcome o Low dose aspirin (LDA), Maternal + Fetal Surveillance • Previous thrombosis o On warfarin  Stop warfarin o LDA + LMWH (treatment dose) • Recurrent early pregnancy loss o LDA + LMWH (prophylaxis dose) • Late fetal loss / Severe PET / FGR o LDA + LMWH (prophylaxis dose)

Question 56

Teratogenic drugs: ``` ACE inhibitors/ARB Androgens Antiepileptics Cytotoxics Lithium Methotrexate Retinoids Warfarin ```

Answer 56

* ACE inhibitors/ARB Renal hypoplasia * Androgens Virilisation of female foetus * Antiepileptics Cardiac, facial, limb, neural tube defects * Cytotoxics Multiple defects, abortion * Lithium Cardiovascular defects * Methotrexate Skeletal defects * Retinoids Ear, cardiovascular, skeletal defects * Warfarin Limb and facial defects

Question 57

NSAIDs and pregnancy

Answer 57

* They work by blocking prostaglandins. * Prostaglandins are important in maintaining the ductus arteriosus in the fetus and neonate. * Prostaglandins also soften the cervix and stimulate uterine contractions at the time of delivery. * NSAIDS are generally avoided in pregnancy unless really necessary (e.g. in rheumatoid arthritis). * They are particularly avoided in the third trimester, as they can cause premature closure of the ductus arteriosus in the fetus. * They can also delay labour.

Question 58

Beta blockers and pregnancy

Answer 58

• Beta-blockers can cause: o Fetal growth restriction o Hypoglycaemia in the neonate o Bradycardia in the neonate

Question 59

ACE Inhibitors and Angiotensin II Receptor Blockers and pregnancy

Answer 59

block the renin-angiotensin system (ACE inhibitors and ARBs) can cross the placenta and enter the fetus. • In the fetus, they mainly affect the kidneys, and reduce the production of urine (and therefore amniotic fluid). • ACE inhibitors and ARBs, when used in pregnancy, can cause: o Oligohydramnios (reduced amniotic fluid) o Miscarriage or fetal death o Hypocalvaria (incomplete formation of the skull bones) o Renal failure in the neonate o Hypotension in the neonate o Renal hypoplasia

Question 60

Opiates and pregnancy

Answer 60

neonatal abstinence syndrome (NAS). Presents 3-72 hours

Question 61

Lithium pregnancy

Answer 61

avoided in 1st trimester: linked with ebsteins anomaly (tricuspid valve is lower on right side of heart) avoid: breastfeeding

Question 62

Selective Serotonin Reuptake Inhibitors

Answer 62

o First-trimester use of paroxetine has a stronger link with congenital malformations o Third-trimester use has a link with persistent pulmonary hypertension in the neonate o Neonates can experience withdrawal symptoms, usually only mild and not requiring medical management

Question 63

Isotreinoin

Answer 63

• Isotretinoin is highly teratogenic, causing miscarriage and congenital defects.

Question 64

Pre-eclampsia

Answer 64

new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine). • A pregnancy-specific multi-system disorder with unpredictable, variable and widespread manifestations o Renal / Hepatic / Cardiovascular / Haematology / CNS / Placenta Classic triad of hypertension, proteinuria and oedema

Question 65

Pre-eclampsia pathophysiology

Answer 65

* When the blastocyst implants on the endometrium, the outermost layer, called the syncytiotrophoblast, grows into the endometrium. It forms finger-like projections called chorionic villi. The chorionic villi contain fetal blood vessels. * Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance and making them more fragile. * The blood flow to these arteries increases, and eventually they break down, leaving pools of blood called lacunae (lakes). * Maternal blood flows from the uterine arteries, into these lacunae, and back out through the uterine veins. Lacunae form at around 20 weeks gestation. * When the process of forming lacunae is inadequate, the woman can develop pre-eclampsia. * Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. * This causes oxidative stress in the placenta (placental ischaemia), and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.

Question 66

Pre-eclampsia risk factors

Answer 66

``` • High-risk factors are: o Pre-existing hypertension o Previous hypertension in pregnancy o Existing autoimmune conditions (e.g. systemic lupus erythematosus) o Diabetes o Chronic kidney disease • Moderate-risk factors are: o Older than 40 o BMI > 35 o More than 10 years since previous pregnancy o Multiple pregnancy o First pregnancy o Family history of pre-eclampsia • Medical risk factors o Pre-existing renal disease o Pre-existing hypertension o Diabetes (pre-existing/gestational) o Connective tissue disease o Thrombophilias (congenital / acquired) ```

Question 67

Pre-eclampsia signs/symptoms

Answer 67

``` o Hypertension, typically >170/100mmHg and proteinuria o Headache (cerebral oedema) o Visual disturbance or blurriness o Nausea and Vomiting o Papilloedema o Right upper quadrant/epigastric pain (liver swelling and hepatic capsule rupture) o Abdominal tenderness o Disorientation o Sudden onset oedema o Hyperreflexia, clonus o Reduced urine output o Platelets <100 x106 /L, abnormal liver enzymes or HELLP syndrome ```

Question 68

Pre-eclampsia Dx

Answer 68

• BP: >140/90 (two occasions) or increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic compared to first trimester • Urinalysis: Proteinuria (1+ or more on urine dipstick) o Urine albumin: creatinine ratio (above 30mg/mmol is significant) o Urine protein: creatinine ratio (above 8mg/mmol is significant * Bloods: FBC, Platelets, U&Es, LFTs, coagulation screen, urate * Cardiotocography: technical means of recording the fetal heartbeat and the uterine contractions during pregnanc * Ultrasound – fetal assessment: Maternal uterine artery Doppler (20-24 weeks) – maybe be a notch

Question 69

Pre-eclampsia Mx

Answer 69

Pre-existing HTN - switch to labetalol, nifedipine or methyldopa Pregnancy induced hypertension/Gestational pregnancy (if after 20 weeks gestation) - Antihypertensives like labetalol, nifedipine, methyldopa, hydralazine Pre-eclampsia (after 20 weeks gestation) including prophylaxis - aspirin 150mg - aspirin 75mg - BP, symptoms and urine dipstick at each antenatal appointment - 1st line: labetolol (no asthma) - 2nd line: nifedipine - 3rd line: Methyldopa (stopped within 2 days of birth and not in depression) - IV hydralazine: critical care - Doxazocin - IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures Planned birth - IM steriods <34 weeks

Question 70

Eclampsia

Answer 70

* refers to the seizures associated with pre-eclampsia. * If pre-eclampsia is not controlled, it can develop into eclampsia which is characterised by grand mal seizures. * Associated with ischaemia/vasospasm

Question 71

Eclampsia Mx

Answer 71

• Make patient safe and note time and length of seizure • Give high flow oxygen • Move patient into left lateral and open airway • Monitor baby (only deliver when mum stabilised) • IV Labetolol • IV Hydralazine • Beware hypotension – fetoplacental unit • IV magnesium sulphate (Loading dose: 4g IV over 5 minutes) is used to manage seizures associated with pre-eclampsia. o Maintenance dose: IV fusion 1g/h o If further seizures administer 2g Mg SO4 o If persistent seizures consider diazepam 10mg IV • Urgent delivery by fasted method usually caesarean section, unless fully dilated and deliverable by assisted vaginal delivery.

Question 72

HELLP syndrome

Answer 72

• HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics: o Haemolysis o Elevated Liver enzymes o Low Platelets

Question 73

VTE in pregnancy Ix

Answer 73

Doppler USS - If iliac vein thrombosis - MRI venography Chest x-ray & ECG CT pulmonary angiogram Ventilation-perfusion (VQ) scan The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.

Question 74

VTE prophylaxis Mx

Answer 74

risk assessment at booking scan and birth • Women at increased risk of VTE should receive prophylaxis with low molecular weight heparin (LMWH) unless contraindicated e.g. enoxaparin, dalteparin and tinzaparin. • Prophylaxis is started as soon as possible in very high-risk patients and at 28 weeks in those at high risk. • It is continued throughout the antenatal period and for six weeks postnatally. • Prophylaxis is temporarily stopped when the woman goes into labour, and can be started immediately after delivery (except with postpartum haemorrhage, spinal anaesthesia and epidurals) • Mechanical prophylaxis may be considered in women with contraindications to LMWH. The options for mechanical prophylaxis are: o Intermittent pneumatic compression with equipment that inflates and deflates to massage the legs o Anti-embolic compression stockings

Question 75

DVT pregnancy Mx

Answer 75

• Low molecular weight heparin (LMWH). E.g. enoxaparin, dalteparin and tinzaparin • LMWH should be started immediately, before confirming the diagnosis in patients where DVT or PE is suspected and there is a delay in getting the scan. Treatment can be stopped when the investigations exclude the diagnosis. • When the diagnosis is confirmed, LMWH is continued for the remained of pregnancy, plus six weeks postnatally, or three months in total (whichever is longer). • There is an option to switch to oral anticoagulation (e.g. warfarin or a DOAC) after delivery. - DOAC but not in breastfeeding or preg o Warfarin (dose dependent: more than 5mg/day, need to convert to LMWH by 6 weeks)

Question 76

PE Mx pregnancy

Answer 76

o Unfractionated heparin: rapid onset of action and dose adjustment can be performed if thrombolytic therapy is administered. o Thrombolysis: may be considered for patients with life-threatening pulmonary embolism and haemodynamic compromise.  Intravenous UFH should be started promptly after thrombolysis and this can be converted to LMWH once stability is achieved. o Surgical embolectomy

Question 77

Stages of labour

Answer 77

1) onset of labour until 10cm cervical dilation 2) 10cm dilation to delivery of baby 3) delivery to deliver of placenta

Question 78

Prostaglandins role?

Answer 78

Stimulate contraction (uterine) and ripen cervix Prostaglandin E2

Question 79

Braxton Hicks contractions

Answer 79

Occasional irregular contractions of the uterus Not true and stay hydrated and relaxed

Question 80

1st stage

Answer 80

``` Cervical dilation and effacement Show release (mucus plug) ``` 1) latent phase: 0-3cm (0.5cm per hour) and irregular contractions 2) active phase: 3-10cm (1cm per hour) and strong regular contractions

Question 81

2nd stage: three ps

Answer 81

Power:strength of contractions - frequency: 3-4 in 10 mins, up to 45 seconds Passenger: size of head, attitude (posture), lie (longitudinal vs transverse vs oblique) and presentation (cephalic, shoulder and breech) Passage: shape of pelvis  Gynaecoid Pelvis: This is the most suitable female pelvic shape  Anthropoid pelvis: There is an oval shaped inlet with large anterio-posterior diameter and comparatively smaller transverse diameter  Android Pelvis: Android shaped pelvis has triangular or heart-shaped inlet and is narrower from the front. African-Caribbean women are more at risk of having an android shaped pelvis

Question 82

Cardinal movements of labour

Answer 82

``` Engagement Descent: -5 (pelvic inlet) , 0 (ischial spines) and +5. Occiput transverse Flexion Internal rotation Extension Restitution and external rotation Expulsion ```

Question 83

Large Gestational Age (large for dates fetus)

Answer 83

>4.5kg estimated fetal weight (EFW) above the 90th centile and AC is >97th centile is considered large for gestational age. • Clinically, the symphyseal-fundal height will be more than 2cm for the gestational age.

Question 84

causes of macrosomia

Answer 84

* Constitutional * Maternal diabetes * Previous macrosomia * Maternal obesity or rapid weight gain * Overdue * Male baby * Polyhydramnios: Excess amniotic fluid * Multiple pregnancy * Macrosomia secondary to gestational diabetes * Occasionally - wrong dates in late bookers, vulnerable women or women who have recently moved from abroad.

Question 85

Macrosomia risks to mother

Answer 85

``` Polyhydramnios Labour dystocia o Shoulder dystocia o Failure to progress o Perineal tears o Instrumental delivery or caesarean o Postpartum haemorrhage o Uterine rupture (rare) ```

Question 86

Macrosomia risks to baby

Answer 86

o Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia) o Neonatal hypoglycaemia o Obesity in childhood and later life o Type 2 diabetes in adulthood

Question 87

Signs/symptoms of polyhydramnios

Answer 87

* Abdominal discomfort * Prelabour rupture of membranes * Preterm labour * Cord prolapse * Large for dates * Malpresentation * Shiny, tense abdomen * Inability to feel fetal parts

Question 88

Investigations polyhydramnios

Answer 88

USS:o USS estimated fetal weight >90th centile, AC>97th Centile o Amniotic Fluid Index (AFI >25cm) o Deepest Pool >8cm * Serology- toxoplasmosis, CMV, Parvovirus * Antibody Screen: Rhesus positive/negative * Oral glucose tolerance test for gestational diabetes * Generic population based charts and customised growth charts (ethnicity, BMI, parity)

Question 89

Large for dates Mx

Answer 89

• Exclude diabetes • Most women with large for gestational age pregnancy will have a successful vaginal delivery. • NICE guidelines (2008) advise against induction of labour only on the grounds of macrosomia. • The main risk with a large for gestational age baby is shoulder dystocia. The risks at delivery can be reduced by: o Delivery on a consultant lead unit o Delivery by an experienced midwife or obstetrician o Access to an obstetrician and theatre if required o Active management of the third stage (delivery of the placenta) o Early decision for caesarean section if required o Paediatrician attending the birth

Question 90

Polyhydramnios management

Answer 90

* Serial USS - growth, LV, presentation | * Induction of labour (IOL) by 40 weeks

Question 91

Multiple pregnancy risk factors

Answer 91

* Assisted conception e.g. clomid, IVF * Ethnicity – higher rates in those of African origin * Geography – Europe 6-9/1000 deliveries, Nigeria 40-50/1000 deliveries, Japan and China 2/1000 * Family history on maternal side * Increased maternal age * Increased parity * Tall women > short women

Question 92

Types of multiple pregnancies

Answer 92

• Monozygotic: identical twins (from a single zygote): splitting of a single fertilised egg (30%) • Dizygotic: non-identical (from two different zygotes): fertilisation of 2 ova by 2 sperm (70%) • Monoamniotic: single amniotic sac • Diamniotic: two separate amniotic sacs • Monochorionic: share a single placenta o depending on the time of splitting of the fertilised ovum can be either monochorionic monoamniotic, monochorionic diamniotic or conjoined twins. • Dichorionic: two separate placentas: always DCDA (dichorionic diamniotic)

Question 93

multiple pregnancies aetiology

Answer 93

* Day 0-3 after fertilisation: Dichorionic, diamniotic (DCDA): morula * Day 4-7 after fertilisation: Monochorionic , diamniotic (MCDA): blastocyst * Day 8-14 after fertilisation: Monochorionic , monoamniotic (MCMA): implanted blastocyst * Day 15 after fertilisation onwards: Conjoined twins: formed embroyonic disc

Question 94

Multiple pregnancies Ix

Answer 94

Booking scan: 11-13+6 - gestational age, number of placentas and aminiotic sacs USS: o Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign o Monochorionic diamniotic twins have a membrane between the twins, with a T sign o Monochorionic monoamniotic twins have no membrane separating the twins

Question 95

Multiple pregnancy signs/symptoms

Answer 95

* Exaggerated pregnancy symptoms e.g. excessive sickness/hyperemesis gravidarum * High AFP (alpha fetoprotein) * Large for dates uterus * Multiple fetal poles

Question 96

Multiple pregnancy risks

Answer 96

``` • Risks to the mother: o Anaemia o Hyperemesis gravidarum o Polyhydramnios o Hypertension/pre-eclampsia o Malpresentation o Spontaneous preterm birth o Instrumental delivery or caesarean o Postpartum haemorrhage/Antepartum haemorrhage – abruption and placenta praevia o Gestational diabetes • Risks to the fetuses and neonates: o Miscarriage o Stillbirth o Fetal growth restriction o Prematurity o Twin-twin transfusion syndrome: only in monochorionic pregnancies o Twin anaemia polycythaemia sequence o Congenital abnormalities o IUD (Single/Both) o Cerebral palsy – twins 8x higher, triplets 47x higher ```

Question 97

Twin-Twin Transfusion Syndrome

Answer 97

fetuses share a placenta. It is called feto-fetal transfusion syndrome in pregnancies with more than two fetuses • When there is a connection between the blood supplies of the two fetuses, one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood. • This causes the donor twin to have a decreased blood volume which affects growth and development and leading to decreased urine output, anaemia and oligohydramnios • Recipient twin increases leading to increased urinary output and polyhydramnios, polycythaemia and eventually heart failure. • Treatment involves fetoscopic laser ablation recommended before 26weeks which can lead to twin anaemia-polycythaemia sequence • If after 26weeks, amnioreduction/septostomy is recommended with aim to deliver at 34-36weeks (but may require preterm delivery).

Question 98

Twin Anaemia Polycythaemia Sequence

Answer 98

* Fetoscopic laser ablation for TTS can lead to twin-anaemia-polycythaemia sequence (TAPS) which is unequal blood counts caused by joining of a few small caliber artery-to-vein vessel anastomoses. * Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute. * One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).

Question 99

Multiple pregnancies Mx

Answer 99

• Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at: o Booking clinic, 20 weeks and 28 weeks gestation • Additional ultrasound scans: fetal growth restriction, unequal growth and twin-twin transfusion syndrome: o 2 weekly scans from 16 weeks for monochorionic twins • Anomaly scan is done at 18-20 weeks. o 4 weekly scans from 20 weeks for dichorionic twins o Deep Vertical Pool, bladder & Umbilical Artery Doppler (UAPI), EFW • Women are given iron and folic acid supplementation, low-dose aspirin (12 weeks) to try to prevent hypertensive disorders. • Corticosteroids are given before delivery to help mature the lungs.

Question 100

Multiple pregnancies delivery

Answer 100

• Monoamniotic twins: 32 and 33 + 6 weeks elective caesarean section: due to the higher risk for cord entanglement • Diamniotic twins: 37 and 37 + 6 weeks o 36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins with steroids • Triplets or more – 35 +6 weeks Caesarean section • Vaginal delivery is possible when the first baby has a cephalic presentation (head first) Caesarean section may be required for the second baby after successful birth of the first baby • Conjoined Twins: MDT, Specialised centres

Question 101

Multiple pregnancies labour Mx

Answer 101

* Epidural analgesia because can be used to facilitate operative delivery * Fetal monitoring: USS & FSE * Syntocinon after twin 1 to maintain contractions and aid delivery * USS to confirm presentation * Intertwin delivery time aimed for <30min * Risk of PPH- active 3rd stage

Question 102

Gestational diabetes

Answer 102

diabetes triggered by pregnancy carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy • It is caused by reduced insulin sensitivity during pregnancy, and resolves after birth. • The most significant immediate complication of gestational diabetes is a large for dates fetus and macrosomia. women are at higher risk of developing type 2 diabetes after pregnancy • Anyone with risk factors should be screened with an oral glucose tolerance test at 24 – 28 weeks gestation. • Women with previous gestational diabetes also have an OGTT soon after the booking clinic.

Question 103

Gestational diabetes - pathology

Answer 103

• Pregnancy is a diabetogenic state due to the influence of placental hormones which lead to a relative insulin deficiency/resistance e.g. Human placental lactogen, cortisol • The consequences include: o Overgrowth of insulin sensitive tissues and macrosomia o Shoulder dystocia and vaginal trauma, increased risks and need for assisted delivery via forceps or caesarean section (CS) o Hypoxaemic state in utero - higher risk of stillbirth o Short term metabolic complications – fetal hypoglycaemia post-delivery o Fetal metabolic reprogramming leading to increase long term risk of obesity, insulin resistance and diabetes + cardiovascular disease

Question 104

Gestational diabetes risk factors

Answer 104

* Previous gestational diabetes * Previous macrosomic baby (≥ 4.5kg) * BMI > 30 * Ethnic origin (black Caribbean, Middle Eastern and South Asian) * Family history of diabetes (first-degree relative) * Polyhydramnios * Glycosuria (1+ on >1 occasion or >= 2+ on one occasion

Question 105

Gestational diabetes OGTT normal values

Answer 105

• Normal results are (NICE) o Fasting: < 5.6 mmol/l o At 2 hours: < 7.8 mmol/l • Normal results (SIGN) o Fasting < 5.1 mmol/l o 2 hour < 8.5 mmol/l

Question 106

Gestational diabetes Mx

Answer 106

- Education - four weekly ultrasound scans to monitor the fetal growth and amniotic fluid volume from 28 to 36 weeks gestation Mx o Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin o Fasting glucose above 7 mmol/l: start insulin ± metformin o Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin - Glibenclamide (sulfonylurea) if they decline insulin ``` The NICE (2015) target levels are: o Fasting: 3.5-5.5 mmol/l o 1 hour post-meal: 7.8 mmol/l o 2 hours post-meal: 6.4 mmol/l o Avoiding levels of 4 mmol/l or below ```

Question 107

Complications of diabetes in pregnancy (both pre-existing and gestational)

Answer 107

* Pre-eclampsia * Neonatal hypoglycaemia, obesity, cardiovascular disease * Macrosomia, obstructed labour, operative delivery, vaginal trauma, 3rd degree tears. * Shoulder dystocia * Polyhydramnios

Question 108

Pre-Existing Diabetes and pregnancy Mx

Answer 108

* HBA1C Monitoring Aim for 48mmol/mol (6.5%) * Avoid pregnancy if HBA1C above 86 mmol/mol (10%) * Stop any embryopathic medication e.g. ACE inhibitors, cholesterol lowering agents * Determine macrovascular & microvascular complications * High Dose Folic Acid 5mg (3 months before conception to 12 weeks of pregnancy) * Low dose aspirin from 12 weeks * Fetal anomaly scan at 18-20 weeks * Regular eye checks for retinopathy * If nephropathy- refer renal team * Safety advice about diabetes & hypoglycaemia – higher risk of hypoglycaemic events with tighter control and pregnancy demands. * Contraception plan * Consider continuous glucose monitoring * Growth scans 4 weekly from 28weeks

Question 109

Diabetes and delivery

Answer 109

• Type 1: 37-38 +6 days weeks (earlier if complications present) o Offer CS if EFW >4.5kg ``` •Gestational diabetes o Insulin treatment 38-39 weeks o Metformin 39- 40 weeks o Diet alone 40 to 41 weeks o If fetal macrosomia/ IUGR/ PET earlier delivery ``` • A sliding-scale insulin regime is considered during labour for women with type 1 diabetes

Question 110

Post natal care diabetes

Answer 110

• Women with gestational diabetes can stop their diabetic medications immediately after birth. They need follow up to test their fasting glucose after at least 6-8 weeks. ``` Babies of mothers with diabetes are at risk of: o Neonatal hypoglycaemia o Polycythaemia (raised haemoglobin) o Jaundice (raised bilirubin) o Congenital heart disease o Cardiomyopathy ```

Question 111

Obesity antenatal care Mx

Answer 111

• Counselling about risks and scan difficulties • Optimum Programme o Nutritional advice and regular exercise o Weight monitoring • Folic Acid 5mg till 12 weeks • Vitamin D 10mg ( healthy start vitamins – Vit C, Vit D, Folic acid 400ug) • Low Dose Aspirin ( 150 mg daily from 12/40 until delivery) • VTE score- (fragmin from booking/28 weeks – beware BMI>50) • OGTT 24-28 weeks • USS growth from 28 weeks • Anaesthetic review in third trimester ( 34 weeks) if BMI 40 or more • MDT in third trimester if BMI>50 or more

Question 112

Preterm gestation

Answer 112

o Extreme preterm : 24-27+6 weeks o Very preterm : 28-31+6weeks o Moderate to late preterm : 32-36+6 weeks

Question 113

Aetiology of preterm birth

Answer 113

* Infection * Over-distention i.e. multiple pregnancy, polyhydramnios * Vascular e.g. placental abruption * Intercurrent illness e.g. pyelonephritis, appendicitis, pneumonia * Cervical incompetence * Idiopathic

Question 114

Risk factors for preterm birth:

Answer 114

* Previous preterm labour * Multiple pregnancy * Uterine anomalies * Age (teenagers) * Parity (either nulliparity or grand multiparity) * Ethnicity * Poor socio-economic status * Smoking * Drugs (especially cocaine) * Low BMI (<20)

Question 115

Small gestational age

Answer 115

• fetus that measures below the 10th centile for their gestational age. • Two measurements on ultrasound are used to assess the fetal size: o Estimated fetal weight (EFW) o Fetal abdominal circumference (AC) • Severe SGA is when the fetus is below the 3rd centile for their gestational age. • Low birth weight is defined as a birth weight of less than 2500g.

Question 116

Causes of SGA

Answer 116

o Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart o Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR), is when there is a small fetus (or a fetus that is not growing as expected) due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta. o Placenta mediated growth restriction (asymmetrical IUGR: Head is large to abdomen) - idiopathic, pre-eclampsia, smoking, alcohol, anaemia, malnutrition, infection, maternal health conditions o Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality - genetic e.g. downs, structural, fetal infection (rubella) • Symmetrical IUGR is where both the fetus’ head and abdomen are small. This may be due to chromosomal abnormalities, TORCH [toxoplasmosis, others like syphilis, varicella-zoster, parvovirus B19, rubella, cytomegalovirus and herpes] infections

Question 117

SGA and risk factor categories

Answer 117

* A single major risk factor means that we should be formally measuring and monitoring fetal growth by means of ultrasound to estimate fetal size from 26-28 weeks, and at regular intervals until approximately 36 weeks. so 28, 32 and 36 weeks * 3 minor risk factors at a minimum requires a growth scan at 34 weeks and if there is an abnormal uterine artery doppler measurement at 20 weeks then they would be monitored as if they had a major risk factor.

Question 118

SGA Mx

Answer 118

* Low-risk women have monitoring of the symphysis fundal height (SFH) at every antenatal appointment from 24 weeks onwards to identify potential SGA. * Biophysical assessment: If the symphysis fundal height is less than the 10th centile, women are booked for serial growth scans with umbilical artery doppler. - can add in CTG Uterine doppler at 20 weeks (uterine arteries should become a low resistance vessel in the 2nd trimester with forward flow to the placenta even in diastole) USS: EFW, AC combined with head circumference and femur length

Question 119

Corticosteroids and magnesium sulphate

Answer 119

o Corticosteroids are given when delivery is planned early, particularly when delivered by caesarean section (planned before 36 weeks) o Magnesium sulphate: some fetal neuroprotection against cerebral palsy if delivery is planned before 32 weeks.

Question 120

Pregnancy and anaemia

Answer 120

Women with anaemia in pregnancy are started on iron replacement (e.g. ferrous sulphate 200mg three times daily). When women are not anaemic, but have a low ferritin (indicating low iron stores), they may be started on supplementary iron B12: Ix for pernicious anaemia o Intramuscular hydroxocobalamin injections o Oral cyanocobalamin tablets Folate: folic acid 400mcg per day and 5mg daily for folate deficiency

Question 121

chicken pox and pregnancy

Answer 121

DNA virus and varicella zoster virus (VZV). Dangerous: o Maternal pneumonitis, hepatitis or encephalitis o Fetal varicella syndrome (7-28 weeks) o Severe neonatal varicella infection (if infected around delivery): 7 days prior • Congenital varicella syndrome occurs in around 1% of cases of chickenpox in pregnancy. It occurs when infection occurs in the first 28 weeks of gestation. The typical features include: o Fetal growth restriction o Microcephaly, hydrocephalus and learning disability o Scars and significant skin changes located in specific dermatomes o Limb hypoplasia (underdeveloped limbs) o Cataracts and inflammation in the eye (chorioretinitis) droplets

Question 122

chicken pox Ix and Mx

Answer 122

IgG for VZV - if not immune: offer varicella vaccine before or after pregnancy A planned delivery should normally be avoided for at least 7 days after the onset of the maternal rash to allow for the passive transfer of antibodies from mother to child.

Question 123

Chicken pox Ix and Mx

Answer 123

Test IgG for VZV If negative give varicella vaccine Varicella-zoster immunoglobulins as post exposure prophylaxis Oral acyclovir 800mg within 24 hours of rash developing and over 20 weeks Avoid contact Analgesia

Question 124

Listeria

Answer 124

Gram +ve bacillus Soil and vegetation May be asymptomatic in maternal or flu like illness or pneumonia or meningoencephalitis Can cause miscarriage or fetal death and severe neonatal death

Question 125

Listeria Mx

Answer 125

Avoid high risk groups (unpasteurised dairy products, processed meats, infected animal miscarriage products and contaminated foods) Ampicillin and gentamicin Trimethoprim and sulfamethoxazole

Question 126

Group B strep Mx

Answer 126

If GBS positive or previous baby affected - penicillin Chorioamnitis: augmenting and metronidazole

Question 127

Congenital toxoplasmosis

Answer 127

Spread via faeces from cat Higher risk later in pregnancy Triad: Intracranial calcification Hydrocephalus Chorioretinitis Mx Pyrimethamine and sulfadzinine Leucovirin to minimise toxicity Spiramycin as an alternative

Question 128

CMV

Answer 128

Primary infection in pregnancy or reactivation (infected saliva or urine of asymptomatic children) Congenital CMV infection: FGR, microcephaly, SN hearing loss, vision loss, learning disability and seizures

Question 129

CMV congenital Mx

Answer 129

TOP Valacyclovir Hyper immune globulin

Question 130

Parvovirus B19 (slapped cheek syndrome)

Answer 130

DNA virus The incubation period lasts from 4-20 days and the infectious period starts about 7-10days before the rash develops * In adults, signs and symptoms include a lacy rash affecting the trunk, back and limbs but adults may be asymptomatic. * Can result in hydrops fetalis (a condition where there is accumulation of fluid in at least 2 fetal compartments) which has a fetal mortality of 50% * Often presents similar to rubella as widespread rash sparing the soles of feet and palms

Question 131

Parvovirus B19 (slapped cheek syndrome) Ix and Mx

Answer 131

• Detection of virus specific IgM • Referral to fetal medicine specialist o Serial USS o Fetal MCA doppler – to identify aplastic anaemia Mx • Maternal infection is self-limited • Avoid contact with other children and pregnant women • Parvovirus B19 fetal infection is associated with severe aplastic anaemia, heart failure and hydrops fetalis. • risk is higher if the infection occurs before 20weeks gestation.

Question 132

Rubella

Answer 132

RNA virus direct contact/respiratory droplet exposure • Women who are not immune to rubella and contract this within the first trimester are at risk of miscarriage, still birth and birth defects Congenital rubella syndrome is caused by maternal infection with the rubella virus during the first 20 weeks of pregnancy. The risk is highest before ten weeks gestation

Question 133

Rubella signs/symptoms

Answer 133

flu-like illness associated with polyarthritis, lymphadenopathy and a facial vesicular rash that spreads to the limbs and trunk. • The features of congenital rubella syndrome to be aware of are (triad of rubella: CRS) o Congenital deafness o Congenital cataracts o Congenital heart disease (PDA and pulmonary stenosis) o Learning disability

Question 134

Rubella Ix and Mx

Answer 134

specific IgG antibody detected after natural infection or vaccination • Blood IgM should be done within 10 days exposure • If patient no immune – consider TOP (early gestation) • Supportive treatment, rest, fluids, paracetamol, avoid contact with other pregnant women • Women planning to become pregnant should ensure they have had the MMR vaccine. When in doubt, they can be tested for rubella immunity. If they do not have antibodies to rubella, they can be vaccinated with two doses of the MMR, three months apart. • Pregnant women should not receive the MMR vaccination, as this is a live vaccine. Non-immune women should be offered the vaccine after giving birth.

Question 135

Measles

Answer 135

paramyxovirus highly contagious • Fever, white spots inside the mouth, runny nose, cough, red eyed and rash • Non teratogenic • However high fever can cause IUGR, miscarriage, microcephaly, still birth and preterm birth • High mortality rate if mother develops pneumonia and encephalitis

Question 136

Influenza

Answer 136

• If infection is virulent – miscarriage/preterm labour vaccine is safe in pregnancy

Question 137

zika virus birth defects

Answer 137

congenital Zika syndrome, which involves: o Microcephaly o Fetal growth restriction o Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy

Question 138

Sepsis

Answer 138

• Life threatening organ dysfunction caused by the body’s response to infection • Sepsis is a condition where the body launches a large immune response to an infection, causing systemic inflammation and affecting the functioning of the organs of the body. It is a significant cause of maternal death. • Severe sepsis is when sepsis results in organ dysfunction, such as hypoxia, oliguria or raised lactate. • Septic shock is defined when arterial blood pressure drops and results in organ hypo-perfusion. • Two key causes of sepsis in pregnancy are: o Chorioamnionitis o Urinary tract infections

Question 139

Chorioamnionitis

Answer 139

* Infection of the chorioamniotic membranes and amniotic fluid. * Chorioamnionitis is a leading cause of maternal sepsis and a notable cause of maternal death (along with urinary tract infections). * It usually occurs in later pregnancy and during labour. * Chorioamnionitis can be caused by a large variety of bacteria, including gram-positive bacteria, gram-negative bacteria and anaerobes.

Question 140

Sepsis Mx

Answer 140

* Continuous maternal and fetal monitoring is required. * Emergency caesarean section may be indicated when there is fetal distress, guided by a senior obstetrician. General anaesthesia is usually required for women with sepsis, as spinal anaesthesia is avoided. * Example regimes include piperacillin and tazobactam (tazocin) plus gentamicin, or amoxicillin, clindamycin and gentamicin. Sepsis 6 - blood lactate, urine output and blood cultures - o2, antibiotics and fluids

Question 141

Initiation of labour

Answer 141

progesterone withdrawal and increases in oestrogen and prostaglandin action. * Oxytocin is released from the posterior pituitary and acts on decidual tissue to promote prostaglandin release. Oxytocin initiates and sustains contractions. * Cervix contains myocytes and fibroblasts and towards term, becomes soft and stretchable due to a decrease in collagen with the increase in enzyme activity. Increased hyaluronic acid reduces the affinity of fibronectin for collagen and the affinity of hyaluronic acid for water causes the cervix to ripen (soften and stretch). * Progressive uterine contractions cause effacement and dilatation of the cervix as the result of shorting of myometrial fibres in the upper uterine segment and stretching and thinning of the lower uterine segment.

Question 142

Prolonged labour duration

Answer 142

There is no normal duration of labour, average for a primiparous woman is ten hours and for parous women, it is 5.5 hours. diagnosed when cervical dilatation is of less than 2cm in 4 hours during active labour.

Question 143

Bishops score

Answer 143

``` o Position o Consistency o Effacement o Dilatation o Station in Pelvis ```

Question 144

True labour contractions

Answer 144

• release of oxytocin, which stimulates the uterus to contract. • True labour is when the timing of contractions become evenly spaced, and the time between them gets shorter and shorter Length of time contraction lasts also increases more intense and painful over time • Contractions tighten the top part of your uterus pushing the baby downward into the birth canal in preparation for delivery.

Question 145

second stage

Answer 145

* Passive second stage of labour is defined as full dilatation of the cervix prior to or in the absence of persistent (occurring with every contraction) involuntary expulsive contractions. * Active second stage of labour is when the baby is visible; or Persistent involuntary expulsive contractions with a finding of full dilatation of the cervix or other signs of full dilatation of the cervix or Active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions.

Question 146

Crowning

Answer 146

large segment of fetal head at the introitus • Labia are stretched to full capacity • Largest diameter of fetal head is encircled by the vulval ring • Burning and stinging feeling for the mother

Question 147

Third stage (active management)

Answer 147

o Includes prophylactic administration of oxytocin (10 units) or Syntometrine (ergometrine in combination with oxytocin) o Cord clamping and cutting o Bladder emptying. o Careful traction is applied to the umbilical cord to guide the placenta out of the uterus and vagina – lowers the risk of postpartum haemorrhage

Question 148

Puerperium and Lactation

Answer 148

* Lactation is initiated by placental expulsion and a decrease in oestrogen and progesterone. * During pregnancy the combination of estrogen and progesterone circulating in the blood appears to inhibit milk secretion by blocking the release of prolactin from the pituitary gland and by making the mammary gland cells unresponsive to this pituitary hormone

Question 149

Oxytocin use and drug name

Answer 149

o Induce labour o Progress labour o Improve the frequency and strength of uterine contractions o Prevent or treat postpartum haemorrhage • Syntocinon is a brand name for oxytocin produced by one drug company. • Atosiban is an oxytocin receptor antagonist that can be used as an alternative to nifedipine for tocolysis in premature labour (when nifedipine is contraindicated

Question 150

Ergometrine

Answer 150

stimulates smooth muscle contraction, both in the uterus and blood vessels. • This makes it useful for delivery of the placenta and to reduce postpartum bleeding. • It may be used during the third stage of labour (delivery of the placenta) and postpartum to prevent and treat postpartum haemorrhage. • It is only used after delivery of the baby, not in the first or second stage. S/E: Hypertension (avoid in pre-eclampsia), diarrhoea, vomiting and angina. • Syntometrine is a combination drug containing oxytocin (Syntocinon) and ergometrine. It can be used for prevention or treatment of postpartum haemorrhage.

Question 151

Prostaglandins

Answer 151

• Dinoprostone

Question 152

Misoprostol

Answer 152

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

Question 153

Mifepristone

Answer 153

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

Question 154

Nifedipine

Answer 154

reduce smooth muscle contraction in blood vessels and the uterus. It has two main uses in pregnancy: o Reduce blood pressure in hypertension and pre-eclampsia o Tocolysis in premature labour, where it suppresses uterine activity and delays the onset of labour

Question 155

Terbutaline

Answer 155

beta 2 agonist • It is used for tocolysis in uterine hyperstimulation, notably when the uterine contractions become excessive during induction of labour.

Question 156

Analgesia in labour Non-pharmacological methods

Answer 156

• Mainly Transcutaneous electrical nerve stimulation (TENS) o 2 electrodes are places on the back on each side of the vertebral column at levels of T10 -L1 and S2-S4. o Current is applied at a frequency of 40-150Hz. • Others – acupuncture, sub-cutaneous sterile water injections, massage and relaxation techniques, water immersion

Question 157

Pharmacological methods: analgesia in labour

Answer 157

simple: paracetamol and codeine Entonox Intramuscular Pethidine or Diamorphine (usually IM): drowsiness, nausea and resp depression (within 2 hours) Patient Controlled Analgesia: IV Remifentanil Epidural: - levobupivacaine or bupivacaine (local anaesthetic), usually mixed with fentanyl • Mechanisms: A fine catheter is placed into the lumbar epidural space (L3-L4) and a local anaesthetic agent such as bupivacaine is injected. Pudenal nerve block: operative vaginal delivery Spinal anaesthesia: operative GA

Question 158

Epidural side effects

Answer 158

o Increased Ferguson reflex: uterine activity due to reflex release of oxytocin due to the presenting stretching the upper vagina and cervix. o Headache after insertion: depending on gauge of cannula o Hypotension o Motor weakness in the legs o Nerve damage o Prolonged second stage o Increased probability of instrumental delivery o High block which may cause respiratory depression in mother • Women need urgent anaesthetic review if they develop significant motor weakness (unable to straight leg raise). • The catheter may be incorrectly sited in the subarachnoid space (within the spinal cord), rather than the epidural space.

Question 159

Failure to progression

Answer 159

problem with the 3Ps - Powers - Passage - Passenger e.g. vertex presentation

Question 160

complications of obstructed labour

Answer 160

o Sepsis – ascending genitourinary tract infection o Postpartum haemorrhage o Fistula formation o Fetal asphyxia o Neonatal sepsis o Uterine rupture – increased risk if previous uterine scar o Obstructed acute kidney injury

Question 161

assessing progress in labour

Answer 161

Vaginal assessment every 4 hours - cervical dilation - descent of presenting part - signs of obstruction Stage 1: Suspected failure to progress is defined as less than 2cm dilatation in 4 hours o Nulliparous <2cm dilation in 4 hours o Parous <2cm dilation in 4 hours or slowing in progress Stage 2: Primiparous: 2 hours (epidural) vs 3 hours Multiparous: 1 hour (epidural) vs 2 hours

Question 162

Partogram

Answer 162

Used in the first stage of labour. Measurements are taken hourly o Cervical dilatation (by a 4-hourly vaginal examination) o Descent of the fetal head (in relation to the ischial spines) o Maternal pulse, blood pressure, temperature and urine output o Fetal heart rate o Frequency of contractions: Uterine contractions are measure in contractions per 10 minutes. When the midwife says “she is contracting 2 in 10”, it means she is having 2 uterine contractions in a 10 minute period. o Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium o Drugs and fluids that have been given crossing alert line: aminotomy - artifically rupturing membranes

Question 163

Aetiology of Fetal Hypoxia

Answer 163

``` • Acute: o Uterine Hyperstimulation o Placental Abruption o Cord Prolapse: cord through the uterus and vagina o Uterine Rupture o Feto-maternal Haemorrhage: become hypoxic o Regional Anaesthesia o Vasa Praevia • Chronic: o Placental insufficiency o Fetal anaemia ```

Question 164

CTG DR C BRAVADO

Answer 164

DR - define risk E.g. pre-eclampsia, antepartum haemorrhage, maternal obesity, diabetes, hypertension, multiple gestation, post-dates gestation, previous c-section, premature rupture of membranes, oxytocin induction/augmentation of labour) C - Contractions: expect 3-5 in 10 mins. too many (uterine hyperstimulation, too little - not progressing) BRA: baseline HR (110-160) V - Variability: 5-25 bpm. Reduced is <5bpm, hypoxia, infection and medication can reduce this. Variability is due to the millisecond-to-millisecond reaction of the sympathetic and parasympathetic activity on the heart and reflects the integrity of the autonomic nervous system A- Accelerations: least 15 beats lasting 15 second or more - fetal movement. at least 2 seperate accelerations every 15 minutes D - decelerations: least 15 beats for at least 15 seconds. They are generally abnormal and should prompt senior review. - early: not pathological - late: hypoxia Overall impression/diagnosis: terminal bradycardia and terminal deceleration (does not recover for 3 minutes) - Emergency C cesction

Question 165

CTG main things to look for

Answer 165

o loss of accelerations o Repetitive deeper and wider decelerations o Rising fetal baseline heart rate o Loss of variability o Normal o Suspicious: a single non-reassuring feature o Pathological: two non-reassuring features or a single abnormal feature o Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes

Question 166

Failure to progress Mx

Answer 166

* Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes * Oxytocin infusion * Instrumental delivery * Caesarean section

Question 167

operative delivery key risks

Answer 167

o Cephalohaematoma with ventouse | o Facial nerve palsy with forceps

Question 168

Forceps requirements

Answer 168

o Fully dilated cervix (10cm) o Occipitoanterior position (Occipitoposterior position is possible with Kielland forceps and ventouse). The position of the head must be known as incorrect placement can lead to maternal and fetal trauma o Ruptured membranes o Cephalic presentation o Engaged presenting part – the fetal head must not be palpable abdominally and must be below the ischial spines o Pain relief o Sphincter (bladder) empty – will need catheterisation

Question 169

ventouse contradictions

Answer 169

o Prematurity (<34weeks) o Face presentation o Suspected fetal bleeding disorder such as Haemophilia o Fetal predisposition to fracture e.g. osteogenesis imperfecta o Maternal HIV or Hepatitis C.

Question 170

Indications of C section

Answer 170

``` o Previous caesarean o Fetal distress o Failure to progress o Symptomatic after a previous significant perineal tear o Placenta praevia o Vasa praevia o Breech presentation o Multiple pregnancy o Uncontrolled HIV infection o Cervical cancer ```

Question 171

Emergency Caesarean Categories

Answer 171

* Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes. * Category 2: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is 75 minutes. * Category 3: Delivery is required, but mother and baby are stable. * Category 4: This is an elective caesarean, as described above

Question 172

C section layers

Answer 172

o Skin o Subcutaneous tissue o Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles) o Rectus abdominis muscles (separated vertically) o Peritoneum o Vesicouterine peritoneum (and bladder) – the bladder is separated from the uterus with a bladder flap o Uterus (perimetrium, myometrium and endometrium) o Amniotic sac

Question 173

Measures to reduce risk of C sections

Answer 173

o There is a risk of aspiration pneumonitis during caesarean section, caused by acid reflux and aspiration during the prolonged period lying flat. H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) are given before the procedure to reduce the risk of this happening. o Prophylactic antibiotics during the procedure to reduce the risk of infection o Oxytocin during the procedure to reduce the risk of postpartum haemorrhage o Venous thromboembolism (VTE) prophylaxis with low molecular weight heparin

Question 174

Breech

Answer 174

* presenting part of the fetus (the lowest part) is the legs and bottom. * This is when the fetus is in longitudinal lie but the presenting part is the fetal buttocks.

Question 175

Types of breech

Answer 175

* Complete breech, where the legs are fully flexed at the hips and knees * Incomplete breech, with one leg flexed at the hip and extended at the knee * Extended breech (frank breech), with both legs flexed at the hip and extended at the knee (most common) * Footling breech, with a foot is presenting through the cervix with the leg extended

Question 176

Breech Mx

Answer 176

• Babies that are breech before 36 weeks often turn spontaneously, so no intervention is advised. • External cephalic version (ECV) can be used at term (37 weeks) to attempt to turn the fetus. - 36 weeks: nulliparous - 37 weeks: previous birth - tocolysis: relax uterus e.g. terbutaline • Rhesus-D negative women require anti-D prophylaxis when ECV is performed. • Where ECV fails, women are given a choice between vaginal delivery and elective caesarean section.

Question 177

Premature labour

Answer 177

breakage of the amniotic sac before the onset of labour.

Question 178

Rupture of membranes (ROM): Spontaneous rupture of membranes (SROM): Prelabour rupture of membranes (PROM): Preterm prelabour rupture of membranes (P‑PROM): Prolonged rupture of membranes (also PROM):

Answer 178

* Rupture of membranes (ROM): The amniotic sac has ruptured. * Spontaneous rupture of membranes (SROM): The amniotic sac has ruptured spontaneously * Prelabour rupture of membranes (PROM): The amniotic sac has ruptured before the onset of labour. * Preterm prelabour rupture of membranes (P‑PROM): The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm). * Prolonged rupture of membranes (also PROM): The amniotic sac ruptures more than 18 hours before delivery.

Question 179

Prophylaxis of Preterm Labour Mx

Answer 179

* Progesterone can be given vaginally via gel or pessary as prophylaxis for preterm labour. * Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery. * This is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation. Cervical Cerclage • Putting a stitch in the cervix to add support and keep it closed.

Question 180

Preterm Prelabour Rupture of Membranes (PPROM) aetiology and risk factors

Answer 180

Aetiology • Infection – this may weaken the tensile strength of the fetal membranes. • Cervical incompetence • Over-distension of uterus (multiple pregnancy or polyhydramnios) • Vascular causes – placental abruption ``` Risk factors: • Previous pre-term labour (20% risk after 1 previous episode, 40% risk after 2 episodes) • Multiple pregnancy • Smoking • Uterine anomalies • Parity (=0 or >5) • Ethnicity • Poor socio-economic status • Drugs (especially cocaine) ```

Question 181

Preterm Prelabour Rupture of Membranes (PPROM) diagnosis

Answer 181

speculum: pooling of amniotic fluid in vagina USS: Oligohydramnios avoid digital exam: risk of infection

Question 182

Preterm Prelabour Rupture of Membranes (PPROM) Mx

Answer 182

monitor for chorioamnionitis (maternal pyrexia, tachycardia, uternine tenderness, vaginal discharge and fetal tachy) Prophylactic antibiotics o Erythromycin 250mg QDS for ten days (every 6 hours), or until labour is established if within ten days. o Co-amoxiclav should be avoided as it causes necrotising enterocolitis in the neonate) • Induction of labour may be offered from 34 weeks to initiate the onset of labour. • Tocolytics – nifedipine is first line for women between 26+0 weeks - 33+6weeks gestation, and can be considered in earlier gestation as well. o If contraindicated, oxytocin receptor antagonists such as atosiban can be offered. • Maternal steroids – to encourage maturation of the fetal lungs to assist in adaption to extrauterine life once delivered. • Magnesium sulphate - given as a 4g IV bolus over 15 minutes followed by an IV infusion of 1g per hour until the birth of the baby or for 24hrs, whichever is sooner, for neuroprotection of the fetus.

Question 183

Preterm Labour with Intact Membranes

Answer 183

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

Question 184

Preterm Labour with Intact Membranes Mx

Answer 184

* Fetal monitoring (CTG or intermittent auscultation) * Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour by stopping uterine contractions (24-33+6 weeks) + maternal steroids (<35 weeks: IM betamethasone) * IV magnesium sulphate: can be given before 34 weeks gestation - protect babies brain

Question 185

Induction of Labour indications

Answer 185

offered at 41-42 weeks gestation o Prolonged pregnancy (an excess of 42 weeks gestation) o Prelabour rupture of membranes o Placental insufficiency and Fetal growth restriction o Pre-eclampsia o Obstetric cholestasis o Existing diabetes o Antepartum haemorrhage: placental abruption and antepartum haemorrhage of uncertain origin o Rhesus isoimmunization o Chronic renal disease

Question 186

Induction of labour Mx

Answer 186

Bishops score of 8: successful score induction of labour Stripping of the membranes: Aseptic conditions – finger is inserted into cervix and the fetal membranes are separated from the lower segment It is used from 40 weeks gestation to attempt to initiate labour in women over their EDD. Medical induction of labour and cervical ripening by administration of prostaglandin E2 (pessaries, gels applied to posterior fornix, oral): Method of choice when the membranes are intact or where the cervix is unsuitable for surgical induction. Pessaries – most commonly used method. Come as 3mg doses, if no response (regular contractions or cervical changes) after 6hours, repeat. Slowly releases local prostaglandins over 24 hours. Artificial rupture of membranes (forewaters) using amniotomy: The cervix should be soft, effaced and at least 2cm dilated The head should be engaged in the pelvis and should be presenting by the vertex. A speculum is placed in the vagina, and the amniotic sac is visualized. A spinal needle is then used to make 1 or more small holes in the sac, thereby very slowly releasing amniotic fluid under direct visualization and allowing the presenting part to descend safely into the pelvis. Medical induction following amniotomy synthetic oxytocin infusion (syntocinon): Artificial rupture of membranes with an oxytocin infusion can also be used to induce labour, although this would only be used where there are reasons not to use vaginal prostaglandins. It can be used to progress the induction of labour after vaginal prostaglandins have been used. Mechanical cervical ripening: Involves inserting a balloon catheter through the cervix which is used to distend the cervical canal over a 12hr period and then removed to allow amniotomy. This is used as an alternative where vaginal prostaglandins are not preferred, usually in women with a previous caesarean section, where vaginal prostaglandins have failed or multiparous women (para ≥ 3).

Question 187

Uterine Hyperstimulation

Answer 187

• Uterine hyperstimulation is the main complication of induction of labour with vaginal prostaglandins. This is where the contraction of the uterus is prolonged and frequent, causing fetal distress and compromise. • The two criteria often given are: o Individual uterine contractions lasting more than 2 minutes in duration o More than five uterine contractions every 10 minutes • Uterine hyperstimulation can lead to: o Fetal compromise, with hypoxia and acidosis o Emergency caesarean section o Uterine rupture

Question 188

Management of uterine hyperstimulation involves:

Answer 188

* Removing the vaginal prostaglandins, or stopping the oxytocin infusion * Tocolysis with terbutaline

Question 189

Maternal collapse: 5Hs

Answer 189

* Head- eclampsia, epilepsy, cerebrovascular accident, vasovagal response * Heart- MI, arrythmias, peripartum cardiomyopathy * Hypoxia- asthma, PE, pulmonary oedema, anaphylaxis * Haemorrhage (most common)- abruption, atony, trauma, uterine rupture, uterine invasion, ruptured aneurysm * wHole body and Hazards- hypoglycaemia, amniotic fluid embolism, septicaemia, trauma, anaesthetic complications, drug overdose

Question 190

Cardiac arrest in pregnancy causes

Answer 190

• The three major causes of cardiac arrest in pregnancy to remember are: o Obstetric haemorrhage e.g Ectopic, placental abruption, praevia, accreta and uterine rupture o Pulmonary embolism o Sepsis leading to metabolic acidosis and septic shock

Question 191

Gravid uterus

Answer 191

• Gravid uterus o Aortocaval compression: From 20 weeks gestation, in the supine position the gravid uterus can compress IVC and aorta reducing venous return o Supine hypotension itself can precipitate maternal collapse, which is usually reversed by turning the woman into the left lateral position o Ventilation difficult – pressure on diaphragm • Fetus/placenta o ‘Steals’ oxygen and circulation from mother o 20% decrease in pulmonary functional residual capacity and a 20% increase in oxygen consumption – more risk of hypoxia • More likely to aspirate • More difficult to intubate

Question 192

Cardiac arrest in pregnancy Mx

Answer 192

left manual uterine displacement or 30-degree tilt if on theatre table usual cpr etc if after 4 minutes: perimortem c section

Question 193

Preg and anaphylaxis

Answer 193

significant intravascular volume redistribution which can lead to decreased cardiac output • Acute ventricular failure and myocardial ischaemia may occur. • Upper airway occlusion secondary to angio-oedema, bronchospasm and mucous plugging of smaller airways all contribute to hypoxia and ventilation difficulties. • Common triggers include drugs, latex, animal allergens and foods. Mx • Remove allergen • High flow oxygen • IM adrenaline 500mcg every 5 mins and IV Crystalloid bolus • Chlorpheniramine 20mg IV (antihistamine) • Hydrocortisone 200mg IV • Salbutamol neb

Question 194

Amniotic Fluid Embolism

Answer 194

Amniotic fluid embolisation is a rare (2 per 100,000 deliveries) but severe condition where the amniotic fluid passes into the mother’s blood. • This usually occurs around labour and delivery. • The amniotic fluid contains fetal tissue, causing an immune reaction from the mother. • This immune reaction to cells from the foetus leads to a systemic illness. • It has more similarities to anaphylaxis than venous thromboembolism. risk factors: age, induction of labour, C Section, multiple pregnancy

Question 195

Pathophysiology AFE

Answer 195

* There are different phases to disease progression; initially pulmonary hypertension may occur due to vascular occlusion either be debris or vasoconstriction. * This often resolves and left ventricular dysfunction or failure develops. * If the woman survives the initial event, she will most likely develop disseminated intravascular coagulopathy (DIC) resulting in a massive postpartum haemorrhage

Question 196

AFE signs/symptoms and Dx

Answer 196

• Presents around the time of labour and delivery but can be postpartum. • It can present similarly to sepsis, pulmonary embolism or anaphylaxis, with an acute onset of symptoms of: o Shortness of breath (acute respiratory distress and CVD collapse) o Hypoxia o Hypotension o Coagulopathy: DIC o Haemorrhage o Tachycardia o Confusion o Seizures o Cardiac arrest • Acute presentation: profound fetal distress Dx: • Zinc coproporphyrin levels increased- not always available

Question 197

AFE Mx

Answer 197

• The overall management of amniotic fluid embolism is supportive. • There are no specific treatments. • Amniotic fluid embolism is a medical emergency – get help immediately. • The initial management of any acutely unwell patient is with an ABCDE approach, assessing and treating: o A – Airway: Secure the airway o B – Breathing: Provide oxygen for hypoxia o C – Circulation: IV fluids to treat hypotension and blood transfusion in haemorrhage o D – Disability: Treat seizures and consider other neurological deficits o E – Exposure • Cardiopulmonary resuscitation and immediate caesarean section are required if cardiac arrest occurs.

Question 198

Cord prolapse

Answer 198

umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. • Amniotic sac ruptures: during labour or trying to induce the start of the labour • There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia. risk factors: malpresentation, preterm labour, 2nd twin, artificial membrane rupture • The most significant risk factor for cord prolapse is when the fetus is in an abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique).

Question 199

Cord prolapse Ix and Mx

Answer 199

suspected where there are signs of fetal distress on the CTG. • A prolapsed umbilical cord can be diagnosed by vaginal examination. • Speculum examination can be used to confirm the diagnosis. Mx: C section Minimal handling and keep cord warm and wet due to vasospasm • When the baby is compressing a prolapsed cord, the presenting part can be pushed upwards to prevent it compressing the cord. o The woman can lie in the left lateral position (with a pillow under the hip) or the knee-chest position (on all fours), using gravity to draw the fetus away from the pelvis and reduce compression on the cord. o Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by caesarean section. • Scan for fetal cardiac activity (if not known to have present within minutes of cord prolapse)

Question 200

Shoulder dystocia

Answer 200

* Shoulder dystocia is when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered. * Shoulder dystocia is often caused by macrosomia secondary to gestational diabetes.

Question 201

Shoulder dystocia signs/symptoms

Answer 201

• Shoulder dystocia presents with difficulty delivering the face and head, and obstruction in delivering the shoulders after delivery of the head. • There may be failure of restitution, where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head. • The turtle-neck sign is where the head is delivered but then retracts back into the vagina. o 'head bobbing' – this is when the head consistently retracts back between contractions during the active second stage

Question 202

Shoulder dystocia Mx

Answer 202

Episiotomy? McRoberts Manueuvre: hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way. Pressure to the anterior shoulder involves pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis. Internal Manoeuvre • Rubins manoeuvre involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis. • Wood’s screw manoeuvre is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery. If this does not work, the reverse motion can be tried, pushing the top shoulder backwards and the bottom shoulder forwards. • Zavanelli manoeuver involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.

Question 203

depression and pregnancy

Answer 203

• Sertraline: least placental exposure • Fluoxetine is thought to the safest (been around longest) • Risks o Persistent hypertension of the newborn o Lower birth weight o Increased early birth (by a matter of days) o Post-partum haemorrhage • Paroxetine – increased congenital cardiac malformations, less safe than other SSRIs Recommendations • Woman with high risk of relapse should be maintained on medication during and after pregnancy • Moderate to severe depression should be treated with anti-depressants

Question 204

Anti-psychotics

Answer 204

• Second generation e.g. Olanzapine, quetiapine o Risk of gestational diabetes in mum • Reduce fertility due to raised prolactin levels – esp first generation • Women with repeated relapses are best maintained on medication • Changing may not always be the best • Avoid rapid discontinuation • Olanzapine and quetiapine have best evidence base

Question 205

Bipolar affective disorder

Answer 205

• High risk of relapse after delivery if mood stabilising medications are discontinued, particularly in the 1st month post-partum Mood stabilisers • Conservations preconception. There is no safe mood stabilisers • Valproate and carbamazepine (most teratogenic) increase neural tube defects and should be avoided • Lamotrigine is less bad than other anti-convulsants and appears safer as the evidence base increases. Cleft palate would be a risk Lithium - advice is still to avoid lithium • Known association with Ebstein’s anomaly • Consider slow reduction preconception: can be reintroduced in 2nd or 3rd trimester • Consider re-introduction immediately post-partum • Regular ECHO and enhanced US Recommendations • High relapse rates in women with bipolar affective disorder medications abruptly • Aim to switch to a safer anti-psychotic e.g. quetiapine or possibly lamotrigine • Valproate and carbamazepine should be avoided in women on childbearing age • Increased monitoring if lithium is required • May need to consider ECT

Question 206

Breastfeeding recommendations: what drugs you can use

Answer 206

• Anti-depressants: sertraline 1st line (no need to change drug during pregnancy) • Antipsychotics: Olanzapine, Quetiapine best evidence but others appear to be ok o Avoid clozapine (risk of agranulocytosis in infant) • Mood stabilisers o Anti-psychotics o Avoid lithium (secreted into breast milk) o Valproate associated with neonatal development problems

Question 207

Baby blues

Answer 207

first week. Brief period of emotional instability • Baby blues may be the result of a combination of: o Significant hormonal changes o Recovery from birth o Fatigue and sleep deprivation o The responsibility of caring for the neonate o Establishing feeding o All the other changes and events around this time • Tearful, mood swings, irritable, anxiety, poor sleep & confusion lasting for 1-2 days but may persist up to 2 weeks

Question 208

Baby blues Mx

Answer 208

• Day 3-10 self-limiting • Support and reassurance (increased social/family support) • Observation to make sure it is not going into a significant mental health problem o Psych review if they fail to resolve

Question 209

Puerperal psychosis

Answer 209

usually presents within 2 weeks risk factors: bipolar, previous puerperal psychosis, 1st degree relative, previous menatl disorder * Depression or mania occurring with rapidly fluctuating symptoms such as mood lability, insomnia and disorientation * Early symptoms are sleep disturbance and confusion * irrational ideas (this is keeping within puerperal psychosis) * Can carry on into Mania, delusions, hallucinations, confusion

Question 210

Puerperal psychosis Mx

Answer 210

* Is an emergency and needs admission to specialised mother-baby unit * Affective symptoms: Antidepressants, mood stabilizers and ECT * Psychotic symptoms: second generation antipsychotics * Medication combined with therapy, reassurance and emotional

Question 211

Post natal depression

Answer 211

• Onset 2-6 weeks postnatally, lasts weeks to months • Postnatal depression is similar to depression that occurs outside of pregnancy, with the classic triad of: o Low mood o Anhedonia (lack of pleasure in activities) o Low energy

Question 212

Post natal depression signs/symptoms

Answer 212

* Typically 3 months after birth: needs to last 2 weeks to be diagnosed * Tearfulness, irritable, anxiety, lack of enjoyment and poor sleep, weight loss, can present as concerns regarding baby * Effects on bonding, child development, marriage, risk suicide

Question 213

Post natal Depression Ix and Mx

Answer 213

* The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week, as a screening tool for postnatal depression. * There are ten questions, with a total score out of 30 points. A score of 10 or more suggests postnatal depression. Mx • Mild- moderate: self help, counselling • Moderate-severe: psychotherapy (CBT) and antidepressants, admission?

Question 214

Antepartum Haemorrhage (APH)

Answer 214

• Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour (birth of the baby)

Question 215

Placental Abruption

Answer 215

normally implanted placenta separates from the wall of the uterus during pregnancy (partially or completely) • Vasospasm followed by arteriole rupture into the decidua; blood escapes into the amniotic sac or further under the placenta and into myometrium • Causes tonic contraction and interrupts placental circulation which causes hypoxia • Results in Couvelaire uterus (blood between muscle fibres so the uterus appears blue and the uterus doesn’t contract well increasing the risk of postpartum haemorrhage)

Question 216

placental abruption risk factors

Answer 216

* UNKNOWN: 70% of cases of placental abruption occur in low-risk pregnancies. * Previous placental abruption * Pre-eclampsia * Bleeding early in pregnancy * Trauma (consider domestic violence): RTA * Multiple pregnancy * Fetal growth restriction * Multigravida * Increased maternal age * Smoking, Cocaine or amphetamine use * Medical Thrombophilias/Renal diseases/Diabetes * Polyhydramnios * Preterm-PROM * Abnormal placenta – The ‘Sick placenta’ * Hypothyroidism

Question 217

placental abruption signs/symptoms

Answer 217

• Sudden onset severe abdominal pain that is continuous (Labour: intermittent) • (backache with posterior placenta) • Preterm labour • Vaginal bleeding (antepartum haemorrhage) • Shock (hypotension and tachycardia)  collapse • Abdominal examination o Uterus LFD or normal o Uterine tenderness o Fetal parts difficult to identify o May be in preterm labour (with heavy show) o Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage • Fetal Condition o Fetal heart rate : bradycardia/ absent (intrauterine death) o CTG shows irritable uterus o (1contraction/minute)/ FH abnormality- tachycardia, loss of variability, decelerations)

Question 218

Severity of Antepartum Haemorrhage

Answer 218

* Spotting: spots of blood noticed on underwear * Minor haemorrhage: less than 50ml blood loss * Major haemorrhage: 50 – 1000ml blood loss * Massive haemorrhage: more than 1000 ml blood loss, or signs of shock

Question 219

Placental abruption Mx

Answer 219

o Urgent involvement of a senior obstetrician, midwife and anaesthetist o 2 x grey cannula (large bore canula) o Bloods include FBC, UE, LFT and coagulation studies o Crossmatch 4-6 units of blood and Kleihauer if Rhesus -ve o Fluid and blood resuscitation as required: be careful with PET: don’t want to fluid overload o CTG monitoring of the fetus o Close monitoring of the mother • Ultrasound can be useful in excluding placenta praevia as a cause for antepartum haemorrhage, but is not very good at diagnosing or assessing abruption. o For fetal heart rate • Antenatal steroids are offered between 24 and 34 + 6 weeks gestation to mature the fetal lungs in anticipation of preterm delivery. C section • Induction of labour- by amniotomy (mild abruption and favourable by cervix) • Expectant Mx (only for minor; allow steroid cover) • (Couvelaire uterus- haematoma bruised uterus)

Question 220

Placenta Praevia

Answer 220

placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus. • Low-lying placenta is used when the placenta edge is within 20mm of the internal cervical os on transabdominal or transvaginal scanning (TVS). • Placenta praevia is used only when the placenta is over the internal cervical os

Question 221

Risk Factors Placenta praevia

Answer 221

* Previous c/section * Previous termination of pregnancy * Advanced maternal age (>40 years) * Multiparity * Assisted conception * Multiple pregnancy * Smoking

Question 222

Placenta praevia risks

Answer 222

``` o Antepartum haemorrhage o Emergency caesarean section o Emergency hysterectomy o Maternal anaemia and transfusions o Preterm birth and low birth weight o Stillbirth ```

Question 223

Placenta Praevia Screening

Answer 223

* Mid-trimester fetal anomaly scan should include placental localisation at 20 weeks * Rescan at 32 and 36 weeks if persistent PP or LLP * Transvaginal scan * Assess cervical length before 34 weeks for risk of preterm labour * MRI if placenta accreta suspected

Question 224

Placenta praevia signs/symptoms

Answer 224

• Painless bleeding >24 weeks • Usually unprovoked but coitus can trigger bleeding • Bleeding can be minor e.g. spotting/ severe • Fetal movements usually present • General: Patient’s condition directly proportional to amount of observed bleeding • Abdomen: o Uterus soft non tender o Presenting part high o Malpresentations –Breech/Transverse/Oblique (due to mass in lower uterus) • Fetal Heart: CTG usually normal • DO NOT perform digital Vaginal Examination or rectal examination until you exclude it! o Speculum Examination may be useful o Opens vaginal wall and doesn’t open uterus

Question 225

Placenta Praevia Mx

Answer 225

* Admit for at least 24 hrs until bleeding has ceased * Anti D if Rh Neg * Antenatal corticosteroids between 24+0 and 35+6 weeks * TEDS- no fragmin unless prolonged stay * Prevent & treat anaemia * Jehovah’s Witness-ensure advanced directive * Delivery plan at /near term: Mg SO4 (neuroprotection 24-32 weeks- if planning delivery): protects against cerebral palsy * Consider at 34+0 to 36+6 weeks if history of PVB or other risk factors for preterm delivery. * Uncomplicated placenta praevia consider delivery between 36+0 and 37+0 weeks

Question 226

Placenta Praevia: Pt Bleeding Mx

Answer 226

o Communication( MW, Obstetrics, Anaesthetists, NNU, Theatre, Haematologist) o 2 Large bore IV access, o FBC, clotting, LFT, U& E , Anti D, Kleihauer (if Rh Neg) o Cross match 4-6 units RBC o May need Major Haemorrhage protocol o IV fluids or transfuse • Assess Fetal wellbeing o Monitor Fetal heart: (CTG after 28 weeks) o Steroids 24-34+6 (up to 35+6weeks) o Mg SO4 (neuro-protection 24-32 weeks- if planning delivery) o Expectant Management if stable o Expedite delivery if actively bleeding: C section (emergency)

Question 227

Placenta praevia complications

Answer 227

``` o Emergency caesarean section o Blood transfusions o Intrauterine balloon tamponade o Uterine artery occlusion o Emergency hysterectomy ```

Question 228

Placenta accreta

Answer 228

• A morbidly adherent placenta: abnormally adherent to the uterine wall o Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond o Placenta increta is where the placenta attaches deeply into the myometrium o Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

Question 229

Placenta accreta risk factors

Answer 229

* Previous placenta accreta * Previous endometrial curettage procedures (e.g. for miscarriage or abortion) * Previous caesarean section * Multigravida * Increased maternal age * Low-lying placenta or placenta praevia

Question 230

Placenta accreta signs/symptoms

Answer 230

present with severe bleeding (antepartum haemorrhage) in the third trimester. • It may be diagnosed on antenatal ultrasound scans, and particular attention is given to women with a previous placenta accreta or caesarean during scanning. • It may be diagnosed at birth, when it becomes difficult to deliver the placenta. It is a cause of significant postpartum haemorrhage.

Question 231

Placenta accreta Mx

Answer 231

MRI: Depth and width • May need extra things, including: o Complex uterine surgery: Prophylactic internal iliac artery balloon o Blood transfusions o Intensive care for the mother o Neonatal intensive care • Delivery is planned between 35 to 36 + 6 weeks gestation to reduce the risk of spontaneous labour and delivery. • Antenatal steroids are given to mature the fetal lungs before delivery C section: - Hysterectomy with placenta remaining o Uterus preserving surgery, with resection of part of the myometrium along with the placenta o Expectant management, leaving the placenta in place to be reabsorbed over time

Question 232

Uterine rupture

Answer 232

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

Question 233

Uterine rupture risk factors

Answer 233

* Previous caesarean section. * Vaginal birth after caesarean (VBAC) * Previous uterine surgery e.g. myomectomy for fibroid removal * Increased BMI * High parity * Increased maternal age * Induction of labour and obstructed labour * Use of oxytocin (syntocinon) or prostaglandins to stimulate contractions

Question 234

Uterine rupture signs/symptoms

Answer 234

acute constant abdominal pain even when the uterus is relaxed which may be referred to the shoulder tip suddenly collapse and on abdominal palpation, fetal parts will be felt easily as fetus may be in intra-abdominal cavity out with the womb. • Uterine rupture presents with an acutely unwell mother and abnormal CTG. • It may occur with induction or augmentation of labour, with signs and symptoms of: o Abdominal pain o Vaginal bleeding o Ceasing of uterine contractions o Hypotension o Tachycardia o Sudden maternal Collapse o Shoulder-tip pain: due to internal haemorrhage o Peritonism

Question 235

Uterine rupture Mx

Answer 235

* Urgent Resuscitation & Surgical management * Communication (MW, Obstetrics, Anaesthetists, NNU, Theatre, Haematologist): Cat 1111 * 2 Large bore IV access, * FBC, clotting , LFT, U& E , Kleihauer ( if Rh Neg) * Xmatch 4-6 units RBC * May need Major Haemorrhage protocol * IV fluids or transfuse (may need O negative blood) * Anti D ( if Rh Neg) * Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Question 236

Vasa praevia

Answer 236

* Vasa praevia is a condition where the fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os. * The fetal membranes surround the amniotic cavity and developing fetus. * The fetal vessels consist of the two umbilical arteries and single umbilical vein. * Vasa praevia is where the vessels are placed over internal cervical os, before the fetus.

Question 237

Vasa Praevia Pathophysiology

Answer 237

• Under normal circumstances, the umbilical cord containing the fetal vessels (umbilical arteries and vein) inserts directly into the placenta. o Velamentous umbilical cord is where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta. o An accessory lobe of the placenta (also known as a succenturiate lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes • In vasa praevia, the fetal vessels are exposed, outside the protection of the umbilical cord or the placenta. • The fetal vessels travel through the chorioamniotic membranes, and pass across the internal cervical os (the inner opening of the cervix). • These exposed vessels are prone to bleeding, particularly when the membranes are ruptured during labour and at birth. This can lead to dramatic fetal blood loss and death

Question 238

Types of vasa praevia

Answer 238

* Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord * Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe

Question 239

signs/symptoms of vasa praevia

Answer 239

* present with antepartum haemorrhage, with bleeding during the second or third trimester of pregnancy. * detected by vaginal examination during labour, when pulsating fetal vessels are seen in the membranes through the dilated cervix. * Clinical- ARM and sudden dark red bleeding and fetal bradycardia / death * Most common scenario is when membranes are ruptured followed by small amount of dark vaginal bleeding and is accompanied by an acute fetal bradycardia and decelerations becoming a significant fetal mortality risk.

Question 240

Vasa Praevia Ix & Mx

Answer 240

•Ultrasound TA & TV with doppler. Therefore it is important to check to feel for pulsations or any cord-like structures before an amniotomy. It is also important to check the fetal head is presenting and engaged before inducing labour or artificially rupturing membranes * Corticosteroids, given from 32 weeks gestation to mature the fetal lungs * Consider inpatient management if risks of preterm birth (32-34 weeks) * Elective caesarean section, planned for 34 – 36 weeks gestation * Where antepartum haemorrhage occurs, emergency caesarean section is required to deliver the fetus before death occurs.

Question 241

Post-Partum Haemorrhage (PPH)

Answer 241

Refers to bleeding (>500ml) after delivery of the baby and placenta. o 500ml after a vaginal delivery o 1000ml after a caesarean section It can be defined as: o Minor PPH – under 1000ml blood loss (without clinical shock) o Major PPH – over 1000ml blood loss (CVD shock) o Moderate PPH – 1000 – 2000ml blood loss o Severe PPH – over 2000ml blood loss It can also be categorised as: o Primary PPH: bleeding within 24 hours of birth o Secondary PPH: from 24 hours to 12 weeks after birth

Question 242

Post partum Haemorrhage causes

Answer 242

o T – Tone (uterine atony [fails to contract] – the most common cause): 70% o T – Trauma (e.g. perineal tear): 20% o T – Tissue (retained placenta): 10% o T – Thrombin (bleeding disorder): <1%

Question 243

Post partum Haemorrhage risk factors

Answer 243

``` o anaemia o previous caesarean section o placenta praevia, percreta, accreta o previous PPH o Previous retained placenta o Multiple pregnancy o Polyhydramnios o Obesity o Fetal macrosomia o (Caution with JW- Advanced Directive) • Identify intrapartum risk factors o prolonged labour o operative vaginal delivery o caesarean section o retained placenta ```

Question 244

Post partum Haemorrhage preventive Mx

Answer 244

* Treating anaemia during the antenatal period * Giving birth with an empty bladder (a full bladder reduces uterine contraction) * Active management of the third stage (with intramuscular oxytocin in the third stage) * Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients

Question 245

Postpartum Haemorrhage Mx

Answer 245

• Resuscitation with an ABCDE approach o Vital Signs: Pulse, BP, CRT, Sats every 15min • Oxygen (regardless of saturations) • Lie the woman flat, keep her warm and communicate with her and the partner • Insert two large-bore cannulas ((14 and 16: grey and orange), 18 (green) or pink if really bad) o Blood Samples: FBC, clotting, fibrinogen, U&E, LFT, Lactate o Group and cross match 6 units • Fluid replacement o Warmed Rapid fluid resuscitation - Crystalloid Hartmann’s, 0.9% N/Saline o Blood Transfusion early o Consider O Neg if life threatening haemorrhage o If DIC/coagulopathy – FFP, Cryoprecipitate, platelets  Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

Question 246

Post partum Haemorrhage Mechanical Mx

Answer 246

* Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”) * Catheterisation (bladder distention prevents uterus contractions) * Expel the clots

Question 247

Post partum Haemorrhage Medical Mx

Answer 247

* 5 units of IV Syntocinon stat (Oxytocin: slow injection followed by continuous infusion) followed by 40 units Syntocinon in 500ml Hartmanns - 125 ml/h * Most cases respond to the above but if they don’t, continue * 500 mg Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension and cardiac disease) * Carboprost/Haemabate (PGF2α) 250mcg IM every 15min ( Max 8 doses) (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma) * Misoprostol 800mcg PR (sublingual) is also a prostaglandin analogue and stimulates uterine contraction * Tranexamic acid 0.5-1g (intravenous) is an antifibrinolytic that reduces bleeding * EUA in theatre if persistent bleeding * CALL CONSULTANT

Question 248

Surgical options for post partum haemorrhage

Answer 248

* ? Vaginal / perineal trauma - ensure prompt repair * ? cervical trauma- theatre * Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding * Tissue Sealants * B-Lynch suture – putting a suture around the uterus to compress it * Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow * Internal Iliac Artery Ligation * Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life

Question 249

Secondary Postpartum Haemorrhage

Answer 249

retained products of conception (RPOC) or infection (i.e. endometritis). * Ultrasound for retained products of conception * Endocervical and high vaginal swabs for infection

Question 250

Post partum problems duration

Answer 250

3rd stage of labour until 6 weeks

Question 251

Perineal Tear risk factors

Answer 251

``` o First births (nulliparity) o Large babies (over 4kg) o Shoulder dystocia o Asian ethnicity o Occipito-posterior position o Instrumental deliveries ```

Question 252

Perineal tears classification

Answer 252

• First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin • Second-degree – including the perineal muscles (superficial and deep), but not affecting the anal sphincter • Third-degree – including the anal sphincter, but not affecting the rectal mucosa o 3A – less than 50% of the external anal sphincter affected o 3B – more than 50% of the external anal sphincter affected o 3C – external and internal anal sphincter affected • Fourth degree – including the anal or rectal mucosa

Question 253

Perineal tears Mx

Answer 253

• First-degree tears usually do not require any sutures. • Larger than first degree occurs: requires sutures to correct the injury. • A third or fourth-degree tear is likely to need repairing in theatre. o Regional anaesthesia o Repair of anal mucosa o Repair of internal and external anal sphincter (overlap the muscle to ensure they come together well) Also o Broad-spectrum antibiotics to reduce the risk of infection o Laxatives to reduce the risk of constipation and wound dehiscence o Physiotherapy to reduce the risk and severity of incontinence If still symptomatic: elective C section in future pregnancies

Question 254

Episiotomy

Answer 254

o A cut is made at around 45 degrees diagonally, from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter. o This is called a mediolateral episiotomy. The cut is sutured after delivery. o Similar to 2nd degree perineal tear into ischioanal fossa

Question 255

Perineal tears complications

Answer 255

o Urinary incontinence o Anal incontinence and altered bowel habit (third and fourth-degree tears) o Fistula between the vagina and bowel (rare) o Sexual dysfunction and dyspareunia (painful sex) o Psychological and mental health consequences

Question 256

VTE post partum Mx

Answer 256

* Low risk – hydration + mobilisation * Mod. risk – 10 days prophylactic LMWH * High risk – 6 weeks prophylactic LMWH

Question 257

Endometritis causes

Answer 257

* Prolonged labour * Prolonged ROM * Multiple vaginal examination * Retained placenta tissue * Caesarean section

Question 258

Endometritis (post) signs/symptoms

Answer 258

• Postpartum endometritis can present from shortly after birth to several weeks postpartum. It can present with: o Foul-smelling discharge or lochia o Bleeding that gets heavier or does not improve with time o Lower abdominal or pelvic pain o Fever o Sepsis

Question 259

Endometritis Ix and Mx

Answer 259

* High vaginal swabs including chlamydia and gonorrhoea if there are risk factors * Blood tests: FBC, CRP, U+Es, Coag, blood cultures * Urine culture and sensitives * Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis). ``` Mx • IV Antibiotics o Co-amoxiclav: use clindamycin instead of co-amoxiclav if you are allergic to penicillin o Metronidazole: anaerobes o +/- Gentamycin • IV fluids ```

Question 260

Retained products of conception signs/symptoms, Ix and Mx

Answer 260

* Vaginal bleeding that gets heavier or does not improve with time * Abnormal vaginal discharge * Lower abdominal or pelvic pain * Fever (if infection occurs) USS • GA: Evacuation of retained products of conception (ERPC). : vacuum aspiration and curettage

Question 261

Asherman’s syndrome

Answer 261

adhesions (sometimes called synechiae) form within the uterus. o Endometrial curettage (scraping) can damage the basal layer of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected. o There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. This can lead to infertility.

Question 262

Candida of the Nipple

Answer 262

* Candidal infection of the nipple can occur, often after a course of antibiotics. * This can lead to recurrent mastitis, as it causes cracked skin on the nipple that create an entrance for infection. * It is associated with oral thrush and candidal nappy rash in the infant * Sore nipples bilaterally, particularly after feeding * Nipple tenderness and itching * Cracked, flaky or shiny areola * Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash

Question 263

Candida of the Nipple Mx

Answer 263

• Both the mother and baby need treatment, or it will reoccur. Treatment is with: o Topical miconazole 2% after each breastfeed o Treatment for the baby (e.g. miconazole gel or nystatin)

Question 264

Lactational amenorrhoea

Answer 264

* Women who are breastfeeding may not have a return to regular menstrual periods for six months or longer (unless they stop breastfeeding). * The absence of periods related to breastfeeding is called lactational amenorrhoea. * Bottle-feeding women will begin having menstrual periods from 3 weeks onwards. This is unpredictable, and periods can be delayed or irregular at first.

Question 265

Contraception After Childbirth

Answer 265

* Fertility is not considered to return until 21 days after giving birth, and contraception is not required up to this point. * The risk of pregnancy is very low before 21 days. After 21 days women are considered fertile, and will need contraception (including condoms for seven days when starting the combined pill or two days for progestogen-only contraception). * Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods). * The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth. * The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks). Risk of VTE * A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than four/six weeks after birth (UKMEC 1), but not inserted between 48 hours and four weeks of delivery (UKMEC 3).