Week 1 Flashcards

Question

**2nd Stage of Labour:** - When does it start/finish? - 7 Components?

Answer 1

= Cervical dilatation from 10 cm to birth of the baby **Components:** 1. Descent of the presenting part/head 2. Rotation of head to occipito -anterior position 3. Crowning of vertex at vaginal introitus 4. Anal dilatation 5. Perineal bulging 6. Passive 2nd stage- descent of fetal head due to uterine contractions 7. Active 2nd stage-bearing down effort by the mother

Answer 2

= Period from birth of the baby to separation and expulsion of the placenta and membranes. - Sign of placental separation: Fresh bleeding - Signs of placental descent: Lengthening of the umbilical cord, uterine fundus rises as placenta descents into lower uterine segment Uterine inversion – if you pull on the cord prior to placental separation

Answer 3

1. Syntocinon (Synthetic oxytocin. IM, IV, and as Infusion) 2. Syntometrine (Syntocinon + Ergometrine) IM 3. Ergometrine IM and IV 4. Misoprostol PR 5. Prostagladin F2 Alpha

Answer 4

1. Mobilisation 2. Waterbirth 3. Opiods 4. Inhalation agents- Entonox ( Oxygen 50%+ Nitrous oxide 50%) 5. TENS = Transcutaneous Electrical Nerve Stimulation 6. Epidural analgesia

Answer 5

Causes of Rise in HR in Mother 1. Maternal sepsis 2. Hemorrhage 3. Pain 4. Physical exertion - eg. labour 5. Dehydration 110-180 normal HR for fetus

Answer 6

1. Fetal hypoxia if contractions are too frequent – wont relax and will cut off blood supply to uterus 2. Perineal trauma 3. Atonic post-partum haemorrhage

Answer 7

**Gravidity**: the number of times a woman has been pregnant, regardless of pregnancy outcome - Nulligravidity: no history of pregnancy = Nulligravid - Primigravidity: history of one pregnancy = Primigravid - Multigravidity: history of two or more pregnancies = Multigravid **Parity**: Nulliparous, Primiparous, Multiparous

Answer 8

- **Fetal age**: Counted as completed weeks of gestation and completed days (0–6) of the current week of pregnancy. - E.g., 32 6/7: The patient is 32 weeks and 6 days pregnant. - **Gestational age**: estimated fetal age (in weeks and days) calculated from the first day of the last menstrual period. - **Conceptional age**: the age (in weeks and days) of the fetus calculated from the day of conception (fertilization)

Answer 9

- **Normal duration of pregnancy:** 40 weeks (280 days) - From conception: 38 weeks (266 days) - **Late-term pregnancy**: a pregnancy between 41 0/7 and 41 6/7 weeks' gestation - **Post-term pregnancy**: a pregnancy that extends beyond ≥ 42 0/7 weeks' gestation or the estimated date of delivery plus 14 days

Answer 10

**Gestional age at birth** - **Periviable birth**: live birth occurring between 20–25 weeks' gestation - **Preterm birth**: live birth before the completion of 37 weeks of gestation (< 37 0/7 weeks' gestation) - **Postterm birth**: live birth after the completion of 42 weeks of gestation (≥ 42 0/7 weeks' gestation)

Answer 11

**Presumptive signs** 1. Amenorrhea 2. Nausea and vomiting 3. Breast enlargement and tenderness 4. Linea nigra: darkening of the midline skin of the abdomen 5. Hyperpigmentation of the areola 6. Abdominal bloating and constipation 7. Increased weight gain 8. Cravings for or aversions to certain foods 9. Increased urinary frequency 10. Fatigue

Answer 12

**Human chorionic gonadotropin (hCG)** - **Site of production**: placental syncytiotrophoblast - **Function**: Maintenance of the corpus luteum during the first 8–10 weeks of pregnancy (LH has a similar function) & Luteal-placental shift: levels decrease after corpus luteum involution (placenta starts synthesizing its own estriol and progesterone) - **Urine β-hCG test (e.g., home pregnancy test)**: Qualitative test (less sensitive than serum pregnancy test). β-hCG can be detected in urine 14 days after fertilization - **Serum β-hCG test:** Quantitative test (high sensitivity). Detectable 6–9 days (on average) after fertilization

Answer 13

Based on risk factors and womans choice Shared care between GP, Midwife and specialist Specialist obstetric hospital care Public/Private hospital

Answer 14

- **Innocent systolic murmur** - Due to a hyperdynamic state. - **Displaced apex beat** - Due to the expanding uterus. - **Varicosities** - The uterus presses against the pelvic veins and vena cava, impairing venous return and subsequently increasing the risk of DVT.

Answer 15

**Skin** 1. Spider angioma 2. Palmar erythema 3. Striae gravidarum: scarring that manifests as erythematous, violaceous, and/or hypopigmented linear striations on the abdomen 4. Hyperpigmentation: chloasma, linea nigra, hyperpigmentation of the nipples 5. Linea nigra and polymorphic eruption of pregnancy **Reproductive system** 1. Uterus: increase in size 2. Vulva and vagina: Vaginal discharge 3. Mammary glands: increase in size; breast fullness and tenderness

Answer 16

1. Placental abruption 2. Placenta previa 3. Vasa previa 4. Uterine rupture 5. Still Birth 6. Bloody Show 7. Cervical trauma

Answer 17

**Definition**: The partial or complete separation of the placenta from the uterus prior to delivery; subsequent hemorrhage occurs from both maternal and fetal vessels. **Epidemiology**: - Incidence: ∼ 0.7–1.2% of pregnancies. - Occurs most often in the third trimester. - The recurrence rate in subsequent pregnancies is 4–15%.

Answer 18

**Types of hemorrhage in placental abruption** The type of hemorrhage depends on the location of the abruption. 1. **Concealed** hemorrhage occurs if the placenta separates from the uterine wall in the middle, but is still attached at the margins. This results in a concealed, retroplacental hemorrhage into the artificial space created between the placenta and the uterus. 2. **Revealed** hemorrhage occurs if the placenta separates at the margins, leading to vaginal bleeding. 3. **Mixed** hemorrhage: combination of retroplacental hematoma and revealed vaginal hemorrhage

Answer 19

**Placental Abruption - Diagnosis** 1. **Ultrasound**: Low (25%) sensitivity for placental abruption. Placental position and fetal biophysical profile should be assessed. Retroplacental hematoma may be visible. 2. **Fetal heart rate tracing**: 3. **Laboratory studies**: CBC, Coagulation studies

Answer 20

**Placenta Previa** - **Definition**: Presence of the placenta in the lower uterine segment, which can lead to partial or full obstruction of the internal os; high risk of hemorrhage (rupture of placental vessels) and birth complications - **Epidemiology**: ∼ 0.5% of all pregnancies - **Risk Factors**: 1. Maternal age > 35 years, multiparity, short intervals between pregnancies 2. Previous curettage or cesarean delivery 3. Previous placenta previa, previous/recurrent abortions

Answer 21

**Placenta Previa - Diagnostics** - Routine prenatal care: transvaginal or transabdominal ultrasound to assess placental position. - In patients with antepartum hemorrhage, avoid digital vaginal examination unless placenta previa has been ruled out on transvaginal ultrasound.

Answer 22

Vaginal delivery should never be attempted outside of the operating room in a patient with low-lying placenta.

Answer 23

**Vasa Previa** = Condition in which the fetal vessels are located in the membranes near the internal os of the cervix, putting them at risk of injury if the membranes rupture. - 1/2500 births - **Diagnostics**: Transabdominal or transvaginal ultrasound with color Doppler shows fetal vessels overlying the internal os and decreased blood flow within fetal vessels. - **Treatment**: Emergency cesarean delivery if there are signs of fetal distress. **Clinical features** 1. Painless vaginal bleeding (fetal blood) that occurs suddenly after rupture of membranes 2. Fetal distress (e.g., fetal bradycardia; decelerations or sinusoidal pattern on fetal heart tracings) 3. Fetal death can occur quickly through exsanguination or asphyxiation if fetal vessels are compressed during labor.

Answer 24

When a routine ultrasound at 18 weeks gestation shows a placenta that reaches the internal cervical os, it is referred to as "placenta previa." Placenta previa is a condition where the placenta partially or completely covers the cervix, the opening of the uterus. This can be a concerning finding as it can lead to complications during pregnancy and childbirth. The management of placenta previa will depend on various factors, including the degree of placental coverage, the woman's medical history, and the presence of any symptoms or complications.

Answer 25

**Preterm labor:** regular uterine contractions with cervical effacement, dilation, or both before 37 weeks' gestation. **Preterm birth** - Live birth between 20 0/7 weeks' and 36 6/7 weeks' gestation - WHO subcategories: - Extremely preterm (< 28 weeks) - Very preterm (28 to < 32 weeks) - Moderate to late preterm (32 to < 37 weeks)

Answer 26

**Nonmodifiable risk factors** 1. History of preterm birth (greatest risk factor) 2. Cervical insufficiency 3. Multiple gestations 4. Polyhydramnios 5. Preterm premature rupture of membranes (PPROM) 6. Antepartum hemorrhage caused by: Placenta previa, Placental abruption 7. Uterine anomalies (e.g., anomalies of Mullerian duct fusion, uterine fibroids) 8. Congenital abnormalities of the fetus

Answer 27

1. Regular uterine contractions and associated symptoms of labor (e.g., lower back pain) 2. Loss of mucus plug (bloody show) 3. Cervical effacement and/or cervical dilation 4. Rupture of membranes

Answer 28

Fetal fibronectin is a protein that attaches the fetal amniotic sac to the uterus.

Answer 29

- **Definition**: administration of tocolytics to inhibit uterine contractions. - **Goal**: prolonging pregnancy to allow for induction of fetal lung maturity and/or transfer to another medical center, if necessary. - **Duration**: up to 48 hours - **Contraindications** 1. Maternal-specific drug contraindications 2. Nonreassuring fetal cardiotocography 3. Intrauterine fetal demise 4. Chorioamnionitis 5. Antepartum hemorrhage with hemodynamic instability 6. Severe preeclampsia or eclampsia 7. Lethal fetal anomaly

Answer 30

**Fetal neuroprotection** - **Definition**: administration of antenatal magnesium sulfate to reduce the risk and severity of neurological disorders (e.g., cerebral palsy). - **Indication**: preterm labor at < 32 weeks' gestation. **Antibiotics** - Indicated for: 1. GBS prophylaxis 2. Treament of PPROM

Answer 31

1. Mothers should avoid modifiable risk factors. 2. Manage cervical insufficiency, if present. 3. Vaginal progesterone supplementation: - Women with a singleton pregnancy at 16–24 weeks' gestation with a prior singleton preterm birth, regardless of cervical length and/or cervical cerclage - Women at ≤ 24 weeks' gestation with a short cervical length (≤ 25 mm)

Answer 32

**Postterm pregnancy**: a pregnancy ≥ 42 0/7 weeks' gestation.

Answer 33

**Late-term pregnancy** - Begin by confirming whether the gestational age and estimated date of delivery for the pregnancy was accurately calculated. - First-trimester prenatal ultrasound is preferred over other methods of determining gestational age and estimated date of delivery. **Postterm pregnancy** - Perform induction of labor by 42 0/6 weeks' gestation. - Induction unsuccessful: Perform C-section. - After 42 weeks' gestation, induction is recommended regardless of cervical favorability in order to avoid complications of postterm pregnancy.

Answer 34

**Post-term Maternal complications** - Associated with increased birth weight and fetal macrosomia: 1. Prolonged stages of labor 2. Obstructed labor 3. Perineal lacerations 4. Postpartum hemorrhage 5. Infections: e.g., chorioamnionitis or endometritis

Answer 35

1. Threatened abortion 2. Inevitable abortion 3. Missed abortion 4. Incomplete abortion 5. Complete abortion 6. Stillbirth The terminology used may differ based on the context: e.g., “miscarriage” may be used when communicating with the patient because of the potentially negative connotations of abortion.

Answer 36

Expectant management - A management strategy that involves serial clinical monitoring (i.e., intermittent screening for symptoms of disease). - Symptoms will resolve or will progress to inevitable, incomplete, or complete abortion.

Answer 37

**Spontaneous abortion (miscarriage):** spontaneous loss of pregnancy before 20 weeks' gestation **Early pregnancy loss:** spontaneous loss of pregnancy before 13 weeks' gestation (i.e., during the first trimester) **Recurrent pregnancy loss:** two or more pregnancy losses occurring before 20 weeks' gestation

Answer 38

**Clinical Features** 1. Vaginal bleeding 2. Abdominal pain or cramping 3. Loss of pregnancy symptoms (e.g., breast tenderness, nausea)

Answer 39

**Clinical evaluation** 1. Bimanual pelvic exam 2. Speculum exam - Assess for cervical dilatation and retained POC. & Confirm that the source of bleeding is uterine. **Laboratory studies** 1. Serial serum β-hCG: Downtrending levels suggest a failed pregnancy.

Answer 40

**Threatened abortion** - Expectant management: Symptoms will resolve or progress to inevitable, incomplete, or complete abortion. - Advise the patient to avoid strenuous physical activity. - Repeat pelvic ultrasound in one week.

Answer 41

**Septic Abortion** - **Definition**: an infection of the placenta and fetus before 20 weeks' gestation which is inevitably associated with fetal death. - **Etiology**: Complication of missed, inevitable, or incomplete abortion, Vaginal and/or uterine instrumentation.

Answer 42

1. Septic abortion 2. Retained products of conception result in release of thromboplastin into systemic circulation → disseminated intravascular coagulation 3. Endometritis

Answer 43

**Stillbirth** = Fetal death after 20 weeks' gestation (also called “intrauterine fetal demise”) **Clinical features** 1. Absence of fetal movements and cardiac activity 2. Delivery of a fetus with no signs of life **Complications** 1. Retained products of conception 2. Endometritis

Answer 44

1. Fallopian tube (∼ 95% of cases): Ampulla (∼ 70%), Isthmus (∼ 15%), Fimbriae (∼ 8%) 2. Interstitial/cornual pregnancy (∼ 2%): implantation of gestational sac in the cornua of a bicornuate or septate uterus 3. Ovary (∼ 3% ) 4. Abdomen (∼ 1%) 5. Cervix (< 1%)

Answer 45

- Every woman of reproductive age with abdominal pain should undergo a pregnancy test, regardless of contraception use. - Up to 20% of patients with ectopic pregnancy can be hemodynamically unstable and require immediate therapy. Do not delay stabilization and definitive treatment to confirm the diagnosis!

Answer 46

1. **FBC**: Anemia may be seen in patients with vaginal bleeding. 2. **Blood type and screen**: ABO and Rh testing to identify patients who might need Rho immunization 3. **LFTs** 4. **U&Es**: to determine baseline liver and renal function

Answer 47

**Transabdominal ultrasound (TAUS)** - Can be used to exclude differential diagnoses (e.g., acute appendicitis) - Provides a general picture of the pelvic anatomy and upper abdomen but is less sensitive than TVUS in detecting extrauterine pregnancy - POCUS can be performed using the transabdominal approach to rapidly rule in IUP if present.

Answer 48

**Exploratory laparoscopy - Indications** 1. Unstable patients suspected of having an ectopic pregnancy 2. In pregnancy of unknown location if the location is still uncertain after 7–10 days Do not delay laparoscopy in unstable patients with suspected ectopic pregnancy!

Answer 49

1. Ectopic pregnancy 2. PID 3. Appendicitis 4. Kidney stones 5. Ovarian cyst rupture 6. Ovarian torsion 7. Pelvic cellulitis

Answer 50

**Approach to Ectopic Pregnancy** **Unstable patients:** - Begin acute stabilization. - Obtain an immediate OB/GYN consult for emergency surgery. **Stable patients:** Determine whether medical, surgical, or expectant management is appropriate. - Consider clinical, laboratory, and radiological findings. - Share decision-making with patients in consultation with OB/GYN. **All patients:** Provide adequate supportive care.

Answer 51

**Methotrexate** **Mechanism of action:** inhibits folate-dependent steps in DNA synthesis to terminate the rapidly dividing ectopic pregnancy. **Indications** 1. Uncomplicated ectopic pregnancies 2. Hemodynamically stable patients 3. Unruptured mass 4. β-hCG ≤ 2,000–5,000 mlU/mL 5. Mass size < 3.5 cm 6. No fetal heartbeat

Answer 52

Asymptomatic patients with very low β-hCG levels may experience spontaneous resolution of ectopic pregnancy without medical or surgical treatment. Consider this approach in select patients after consultation with OB/GYN.

Answer 53

Suspect ruptured ectopic pregnancy in patients in their first trimester with any of the following: 1. Clinical features of shock: e.g., tachycardia, hypotension, pallor 2. Severe abdominal or pelvic pain 3. Peritoneal signs on examination 4. Significant vaginal bleeding 5. Clinical deterioration after receiving MTX therapy **Acute stabilization** 1. Start immediate IV fluid resuscitation. 2. Rapidly deliver blood transfusion as soon as blood products are available. 3. If hypotension persists, start vasopressors.

Answer 54

Vaginal bleeding, Closed cervix & fetal heart rate present = the woman has either had a threatened abortion.

Answer 55

After 9 weeks = surgical abortion. Abortions can be performed at up to week 20 of pregnancy in WA. Abortion after 20 weeks is very restricted.

Answer 56

**PPH:** Blood loss ≥ 1000 mL or blood loss manifesting with features of hypovolemia within 24 hours of delivery. **Primary PPH:** blood loss ≤ 24 hours postpartum (more common) **Secondary PPH:** blood loss from 24 hours to 12 weeks postpartum

Answer 57

**Primary PPH** 1. Uterine atony 2. Uterine inversion 3. Abnormal placental separation - Retained placenta or Abnormal placentation 4. Birth trauma 5. Velamentous cord insertion **Secondary PPH** 1. Retained products of conception 2. Subinvolution of the placental site 3. Coagulation disorder - Acquired or Inherited 4. Postpartum endometritis

Answer 58

**Primary PPH - Uterine Atony** - **Definition**: Failure of the uterus to effectively contract after complete or incomplete delivery of the placenta, which can lead to severe postpartum bleeding from the myometrial vessels. - **Epidemiology**: Most common cause of PPH cases (approx. 80%) - **Pathophysiology**: Normally, the myometrium contracts and compresses the spiral arteries, which stops bleeding after delivery. Failure of the myometrium to effectively contract can lead to rapid and severe hemorrhage.

Answer 59

**Primary PPH - Uterine Atony** **Clinical features** 1. Profuse vaginal bleeding 2. Soft, enlarged (increased fundal height), boggy ascending uterus **Diagnosis** 1. Bimanual pelvic exam after emptying the bladder. 2. Speculum examination of the vagina and cervix to evaluate possible sources of extrauterine bleeding (e.g., vaginal injury caused during birth) **Complications** 1. Anemia 2. Hypovolemic shock 3. Sheehan syndrome

Answer 60

**Primary PPH - Uterine Inversion** - **Definition**: An obstetric emergency in which the uterine fundus collapses into the endometrial cavity, resulting in a complete or partial inversion of the uterus, usually following vaginal delivery. - **Epidemiology**: Uncommon complication of vaginal birth, Morbidity and mortality may occur in ∼ 41% of cases - **Pathophysiology**: Partial uterine wall relaxation → prolapse of the uterine wall through the cervical orifice, and if simultaneous downward traction of the uterus is performed → inversion of the uterus

Answer 61

**Degree of inversion** 1. Partial uterine inversion: uterine fundus collapses into the endometrial cavity, without surpassing the cervix 2. Complete uterine inversion: uterine fundus collapses into the endometrial cavity and descends through the cervix, but remains within the vaginal introitus 3. Uterine prolapse: uterine fundus descends through the vaginal introitus

Answer 62

1. Uncontrolled cord traction and/or excessive fundal pressure (Credé maneuver) during the third stage of labour 2. Fetal macrosomia 3. Previous uterine inversion 4. Use of uterine muscle relaxants during the antepartum period (e.g., MgSO4) 5. Difficult removal of the placenta 6. Nulliparity 7. Uterine anomalies (e.g., relaxed lower uterine segment and cervix) 8. Uterine leiomyoma 9. Placenta accreta 10. Retained placental tissue. 11. Prolonged delivery

Answer 63

**Complications of Uterine Inversion** 1. Hypovolemic shock 2. Neurogenic shock 3. Maternal death

Answer 64

**Primary PPH: Retained placenta** - **Definition**: Retention of the placental tissue inside the uterine cavity following the first 30 min postpartum. - **Epidemiology**: Approx. 3% of vaginal deliveries - **Etiology:** 1. Atonic uterus: 2. Placenta accreta spectrum 3. Premature closure of the cervix obstructing placental expulsion

Answer 65

**Primary PPH - Retained placenta** **Classification** 1. Adherent placenta: a placenta that is not detached because of insufficient uterine contractions (e.g., uterine atony) 2. Trapped placenta: a detached placenta that cannot be delivered spontaneously or with light cord traction because of cervical closure **Clinical Features:** 1. Main feature: severe bleeding before placental delivery 2. Physical examination: Inability to completely separate the placenta during the third stage of labor 3. Speculum inspection: visualization of placental fragments or fetal membranes within the uterus **Diagnosis**: 1. Postpartum manual palpation and speculum inspection of the placenta and fetal membranes 2. Ultrasound: showing a focal endometrial mass

Answer 66

**Complications of PPH** 1. Anemia 2. Hypovolemic shock 3. Thromboembolism 4. Sheehan syndrome 5. Infection 6. Maternal death 7. Disseminated intravascular coagulation 8. Fetal death (due to velamentous cord insertion) 9. Abdominal compartment syndrome

Answer 67

**Primary PPH - Abnormal placentation** - **Definition**: Defective decidual layer of the placenta leading to abnormal attachment and separation during postpartum period - **Epidemiology**: Placental detachment abnormalities due to anatomical causes occur in up to 1% of all pregnancies. - **Pathophysiology**: The exact pathogenesis is unknown - Two main theories include 1. Defective decidua: complete or partial lack of decidua in an area of previous scarring within the endometrial-myometrial interface 2. Excessive trophoblastic invasion: abnormal growth → uncontrolled invasion of villi through the myometrium, including its vascular system

Answer 68

The types of abnormal placental attachment: Placenta Accreta “Attaches” to the myometrium, placenta Increta “Invades” the myometrium, and placenta Percreta “Perforates” the myometrium.

Answer 69

Risk factors - Any prior damage to the endometrium 1. History of uterine surgery (e.g., endometrial ablation, hysteroscopic removal of intrauterine adhesions, dilatation, curettage) 2. Prior births by cesarean delivery 3. Placenta previa 4. Multiparity 5. Advanced maternal age 6. Assisted reproduction procedures 7. Asherman syndrome

Answer 70

**Clinical features of Abnormal placentation** 1. Abnormal uterine bleeding 2. Postpartum hemorrhage at the time of attempted manual separation of the placenta 3. Fever 4. Rarely, hematuria in placenta percreta **Prognosis** - Morbidity is approx. 27% - Placenta percreta has the highest complication rate.

Answer 71

Birth trauma can result in bleeding lacerations, puerperal hematomas, and/or uterine rupture. **Puerperal hematoma **= an accumulation of blood in the vulva, vagina, or retroperitoneum, most commonly caused by iatrogenic injury during childbirth. Subtypes include: 1. Vulvar hematoma: accumulation of blood in the vulvar soft tissue 2. Vaginal hematoma: accumulation of blood in the vaginal soft tissue 3. Retroperitoneal hematoma: accumulation of blood in the retroperitoneal space

Answer 72

**Primary PPH - Puerperal hematoma** **Epidemiology** - Second most common cause (20% of individuals with postpartum hemorrhage) - Estimated incidence of puerperal hematoma ranges from 1:300 to 1:1500 deliveries. **Clinical features** 1. Features of hematoma or bleeding laceration of the female genital tract 2. Severe pain in the labia, pelvis and/or perineum ≤ 24 hours after delivery 3. Severe bleeding, hypovolemic shock 4. Vaginal hematoma: protruding, tender, palpable vaginal mass 5. Features of retroperitoneal hematoma 6. Pelvic pain 7. Signs and symptoms of hypovolemia (e.g., tachycardia, hypotension, diaphoresis, pale skin, dizziness) 8. Features of uterine rupture

Answer 73

**Primary PPH - Velamentous Cord Insertion** **Definition**: Abnormal cord insertion into chorioamniotic membranes, resulting in exposed vessels only surrounded by thin fetal membranes, in the absence of protective Wharton jelly. **Epidemiology:** - Occurs in 1% of single pregnancies - Up to 15% in twin pregnancies - Associated with increased risk of hemorrhage during the third stage of labor **Risk factors** 1. Placenta previa 2. Low-lying placenta 3. Multiple pregnancies 4. Assisted reproduction procedures (e.g., in vitro fertilization) 5. Succenturiate placenta

Answer 74

**Complications of Velamentous Cord Insertion** 1. Vasa previa 2. Fetal death 3. Premature infant 4. Fetal growth restriction 5. Fetal malformation

Answer 75

**Secondary PPH - Subinvolution of the placental site** - **Definition**: A condition in which the uterus remains abnormally large following delivery because of the persistence of dilated uteroplacental vessels - **Epidemiology**: Occurs most commonly in the second week postpartum. Second most common cause of secondary postpartum hemorrhage (13% of affected individuals). - **Risk factors** 1. Multiparity 2. Cesarean delivery 3. Uterine atony 4. Endometritis 5. Coagulopathy 6. Retained products of conception

Answer 76

**Secondary PPH - Subinvolution of the placental site** **Clinical features** 1. Abnormal, severe uterine bleeding, most commonly during second week postpartum 2. Fever, chills 3. Lower abdominal pain 4. Signs of hypovolemia

Answer 77

SMALL FOR GESTATIONAL AGE 1. Wrong dates 2. Fetal growth restriction 3. Oligohydramnios 4. Preterm rupture of membranes 5. Fetal death in utero 6. Transverse lie

Answer 78

1. Wrong dates 2. Fetal macrosomia 3. Polyhydramnios 4. Multiple pregnancy- twins, triplets 5. Uterine fibroids

Answer 79

1. Miscarriage 2. Ectopic pregnancy 3. Pregnancy of unknown location (PUL) 4. Gestational trophoblastic disease (GTD) 5. Genital tract pathology 6. Unexplained

Answer 80

**Miscarriage** * Bleeding in first trimester * Bleeding in first trimester affects 20-30% of pregnancies. * Approximately 50% of those who bleed may miscarry. * 10-15% of clinically recognised pregnancies will miscarry. **Symptoms and Signs** 1. Vaginal bleeding: Spotting or Heavy bleeding with clots. 2. Pain and cramping in lower abdomen. 3. Haemodynamic compromise: Weakness, dizziness, collapse, vasovagal attacks- mainly in incomplete miscarriage

Answer 81

**Classification of miscarriages** * **Anembryonic pregnancy ( Blighted ovum)**: Empty gestation sac with mean diameter >25mm, there is no fetal pole * **Missed miscarriage**: Fetal pole >7mm with no cardiac activity. Usually diagnosed at routine scan for dating. No bleeding or pain. Miscarriage is called missed because the woman has no pain or bleeding * **Pregnancy of Unknown Location (PUL):** Empty uterus on scan. Needs serial hCG to confirm whether complete miscarriage, pregnancy too early to visualize or ectopic pregnancy

Answer 82

**Investigations** 1. FBC 2. Group and Hold if heavy bleeding 3. Rhesus status for all pregnancy related bleeding 4. Serum Beta hCG especially if Pregnancy of Unknown Location 5. Pelvic Ultrasound scan: Transabdominal and Transvaginal ultrasound scan to confirm pregnancy, site of pregnancy, gestational age, viability, multiple gestation

Answer 83

**Risk factors for ectopic pregnancy** 2. Previous ectopic pregnancy 2. Previous tubal surgery 3. History of pelvic inflammatory disease- chlamydia/gonorrhoea 4. History of subfertility 5. Advancing maternal age 6. History of smoking 7. Assisted conception- IVF, ICSI 8. Intrauterine contraceptive device in situ 9. Emergency contraception use

Answer 84

**Investigations** 1. Urinary hCG 2. Serum quantitative hCG- important to decide method of treatment and confirm successful resolution of trophoblastic tissue ( especially after medical management or in spontaneous resolution) 3. FBC 4. Group and Hold and Crossmatch if blood transfusion is necessary and for Blood group and Rhesus status 5. Pelvic ultrasound scan: A combination of lower abdominal and transvaginal scan Do not send a patient in shock for a formal ultrasound scan. FAST (Focussed Abdominal Scan in Trauma) scan may be performed in ED to confirm haemoperitoneum!!