Zero to Finals Obstetrics

Question 1

Explain the stages of labour:

Answer 1

There are three stages of labour:

• The first stage is from the onset of labour (true contractions) until 10cm cervical dilatation.
• The second stage is from 10cm cervical dilatation to delivery of the baby.
• The third stage is from delivery of the baby to delivery of the placenta.

Question 2

What role do prostaglandins play in pregnancy?

Answer 2

They play a crucial role in menstruation and labour by stimulating contraction of the uterine muscles. They also have a role in the ripening of the cervix before delivery.

One key prostaglandin to be aware of is prostaglandin E2. Pessaries containing prostaglandin E2 (dinoprostone) can be used to induce labour.

Question 3

Explain the first stage of labour and the rate of progression:

Answer 3

The first stage of labour is from the onset of labour (true contractions) until the cervix is fully dilated to 10cm.

• Latent phase: From 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
• Active phase: From 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
• Transition phase: From 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

Question 4

What are the three P’s in regard to the second stage of labour?

Answer 4

The second stage of labour lasts from 10cm dilatation of the cervix to delivery of the baby. The success of the second stage depends on “the three Ps”: power, passenger and passage.

Passenger: the four descriptive qualities of the fetus - size, attitude, lie, presentation.

Question 5

What is meant by active management in the third stage of labour?

Answer 5

Active management of the third stage is where the midwife or doctor assist in delivery of the placenta - reduces the risk of haemorrhage.

Active management involves giving a dose of intramuscular oxytocin to help the uterus contract and expel the placenta. Careful traction is applied to the umbilical cord to guide the placenta out of the uterus and vagina.

Question 6

Skim this summary of Braxton-Hicks contractions.

Answer 6

Braxton-Hicks contractions are occasional irregular contractions of the uterus. They are usually felt during the second and third trimester. Women can experience temporary and irregular tightening or mild cramping in the abdomen. These are not true contractions, and they do not indicate the onset of labour. They do not progress or become regular. Staying hydrated and relaxing can help reduce Braxton-Hicks contractions.

Question 7

Latent first stage vs established first stage of labour:

Answer 7

The latent first stage is when there are both:

Painful contractions

Changes to the cervix, with effacement and dilation up to 4cm

The established first stage of labour is when there are both:

Regular, painful contractions

Dilatation of the cervix from 4cm onwards

Question 8

Prolonged rupture of membranes

Answer 8

Prolonged rupture of membranes (also PROM): The amniotic sac ruptures more than 18 hours before delivery.

Question 9

Skim

Answer 9

Babies are considered non-viable below 23 weeks gestation. Generally, from 23 to 24 weeks, resuscitation is not considered in babies that do not show signs of life. Babies born at 23 weeks have around a 10% chance of survival. From 24 weeks onwards, there is an increased chance of survival, and full resuscitation is offered.

Question 10

What is given as prophylaxis for preterm labour?

Answer 10

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.

Cervical cerclage involves putting a stitch in the cervix to add support and keep it closed. This involves a spinal or general anaesthetic. The stitch is removed when the woman goes into labour or reaches term.

Question 11

How is rupture of membranes identified?

Answer 11

Rupture of membranes can be diagnosed by speculum examination revealing pooling of amniotic fluid in the vagina. No tests are required.

Question 12

Preterm Prelabour Rupture of Membranes managed?

Answer 12

Prophylactic antibiotics should be given to prevent the development of chorioamnionitis.

Induction of labour may be offered from 34 weeks to initiate the onset of labour.

Question 13

What is preterm labour with intact membranes?

Answer 13

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

Question 14

How is preterm labour managed?

Answer 14

There are several options for improving the outcomes in preterm labour:

• Fetal monitoring (CTG or intermittent auscultation)
• Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
• Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
• IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain
• Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth.

Question 15

What is tocolysis and what medication is used?

Answer 15

Tocolysis can be used before 34 weeks gestation in preterm labour to delay delivery and buy time for further fetal development, administration of maternal steroids or transfer to a more specialist unit (e.g. with a neonatal ICU). It is only used as a short term measure (i.e. less than 48 hours).

Tocolysis involves using medications to stop uterine contractions. Nifedipine, a calcium channel blocker, is the medication of choice for tocolysis. Atosiban is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.

Question 16

Explain the use of antenatal steroids?

Answer 16

Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery. They are used in women with suspected preterm labour of babies less than 36 weeks gestation.

Question 17

Explain the use of magnesium sulphate in pregnancy.

Answer 17

Giving the mother IV magnesium sulfate helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy. Magnesium sulphate is given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth.

Question 18

What are the complications with using magnesium sulphate to protect against cerebral palsy?

Answer 18

Mothers need close monitoring for magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are:

• Reduced respiratory rate
• Reduced blood pressure
• Absent reflexes

Question 19

What are the indications for induction of labour?

Answer 19

Induction of labour can be used where patients go over the due date. IOL is offered between 41 and 42 weeks gestation.

• Prelabour rupture of membranes
• Fetal growth restriction
• Pre-eclampsia
• Obstetric cholestasis
• Existing diabetes
• Intrauterine fetal death

Question 20

What scoring system is used to determine whether to induce labour?

Answer 20

The Bishop score is a scoring system used to determine whether to induce labour.

Question 21

What are the options for inducting labour?

(in order of first line)

Answer 21

Membrane sweep

Vaginal prostaglandin E2 (dinoprostone)

Cervical ripening balloon (CRB)

Artificial rupture of membranes

Oral mifepristone (anti-progesterone) plus misoprostol

Question 22

Membrane sweep

Answer 22

Membrane sweep involves inserting a finger into the cervix to stimulate the cervix and begin the process of labour. It can be performed in antenatal clinic, and if successful, should produce the onset of labour within 48 hours. A membrane sweep is not considered a full method of inducing labour, and is more of an assistance before full induction of labour. It is used from 40 weeks gestation to attempt to initiate labour in women over their EDD.

Question 23

Vaginal prostaglandin E2 (dinoprostone)

Answer 23

Vaginal prostaglandin E2 (dinoprostone) involves inserting a gel, tablet (Prostin) or pessary (Propess) into the vagina. The pessary is similar to a tampon, and slowly releases local prostaglandins over 24 hours. This stimulates the cervix and uterus to cause the onset of labour. This is usually done in the hospital setting so that the woman can be monitored before being allowed home to await the full onset of labour.

Question 24

Cervical ripening balloon (CRB)

Answer 24

Cervical ripening balloon (CRB) is a silicone balloon that is inserted into the cervix and gently inflated to dilate the cervix. 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 25

Artificial rupture of membranes

Answer 25

**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.

Question 26

When are oral mifepristone (anti-progesterone) plus misoprostol indicated?

Answer 26

Oral mifepristone (anti-progesterone) plus misoprostol are used to induce labour where intrauterine fetal death has occurred.

Question 27

What are the two means for monitoring during the induction of labour?

Answer 27

Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour Bishop score before and during induction of labour to monitor the progress.

Question 28

What are the options for failure to progress through the first stage of labour?

Answer 28

Most women will give birth within 24 hours of the start of induction of labour. The options when there is slow or no progress are: * Further vaginal prostaglandins * Artificial rupture of membranes and oxytocin infusion * Cervical ripening balloon (CRB) * Elective caesarean section

Question 29

What is the main complication of vaginal prostaglandins?

Answer 29

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.

Question 30

How is uterinehyperstimulation defined?

Answer 30

Individual uterine contractions lasting more than 2 minutes in duration More than five uterine contractions every 10 minutes

Question 31

Uterine hyperstimulation can lead to:

Answer 31

* Fetal compromise, with hypoxia and acidosis * Emergency caesarean section * Uterine rupture

Question 32

How is uterine hyperstimulation managed?

Answer 32

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

Question 33

What is CTG?

Answer 33

Cardiotocography (CTG) is used to measure the fetal heart rate and the contractions of the uterus. It is also known as electronic fetal monitoring. It is a useful way of monitoring the condition of the fetus and the activity of labour.

Question 34

Skim the indications for continuous CTG:

Answer 34

Sepsis Maternal tachycardia (\> 120) Significant meconium Pre-eclampsia (particularly blood pressure \> 160 / 110) Fresh antepartum haemorrhage Delay in labour Use of oxytocin Disproportionate maternal pain

Question 35

What are the 5 key features to look for on a CTG?

Answer 35

Contractions – the number of uterine contractions per 10 minutes Baseline rate – the baseline fetal heart rate Variability – how the fetal heart rate varies up and down around the baseline. Accelerations – periods where the fetal heart rate spikes Decelerations – periods where the fetal heart rate drops

Question 36

What do accelerations indicate?

Answer 36

Accelerations are generally a good sign that the fetus is healthy, particularly when occurring alongside contractions of the uterus.

Question 37

What are decelerations indications of?

Answer 37

Decelerations are a more concerning finding. The fetal heart rate drops in response to hypoxia. The fetal heart rate is slowing to conserve oxygen for the vital organs.

Question 38

There is a “rule of 3’s” for fetal bradycardia when they are prolonged:

Answer 38

3 minutes – call for help 6 minutes – move to theatre 9 minutes – prepare for delivery 12 minutes – deliver the baby (by 15 minutes)

Question 39

Skim how to assess a CTG in a structured way:

Answer 39

DR C BRaVADO is a mnemonic often taught to assess the features of a CTG in a structured way. It involves assessing in order: DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG) C – Contractions BRa – Baseline Rate V – Variability A – Accelerations D – Decelerations O – Overall impression (given an overall impression of the CTG and clinical picture)

Question 40

What does oxytocin do?

Answer 40

Oxytocin stimulates the ripening of the cervix and contractions of the uterus during labour and delivery. It also plays a role in lactation during breastfeeding.

Question 41

Indications of giving oxytocin:

Answer 41

Infusions of oxytocin are used to: * Induce labour * Progress labour * Improve the frequency and strength of uterine contractions * Prevent or treat postpartum haemorrhage

Question 42

When is Misoprostol used?

Answer 42

Misoprostol is a prostaglandin analogue, meaning it 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 43

When is mifepristone used?

Answer 43

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 44

When is nifedipine used?

Answer 44

Nifedipine is a calcium channel blocker that acts to reduce smooth muscle contraction in blood vessels and the uterus. It has two main uses in pregnancy: * Reduce blood pressure in hypertension and pre-eclampsia * Tocolysis in premature labour, where it suppresses uterine activity and delays the onset of labour

Question 45

What is tranexamic acid and when is it used?

Answer 45

Tranexamic acid is an **antifibrinolytic** that reduces bleeding. It binds to fibrinogen and prevents it from converting to plasmin. Plasmin is an enzyme the helps break down fibrin blood clots. Therefore, tranexamic acid helps prevent the breakdown of blood clots. It also inhibits the action of fibrin, a protein involved in the formation of blood clots. Tranexamic acid is used in the prevention and treatment of postpartum haemorrhage.

Question 46

How are women monitored in the first stage of labour?

Answer 46

Women are monitored for their progress in the first stage of labour using a partogram. It is worth becoming familiar with partograms and how they are recorded.

Question 47

Skim what is recorded on a partogram

Answer 47

* Cervical dilatation (measured by a 4-hourly vaginal examination) * Descent of the fetal head (in relation to the ischial spines) * Maternal pulse, blood pressure, temperature and urine output * Fetal heart rate * Frequency of contractions * Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium * Drugs and fluids that have been given

Question 48

What interventions are used to aid progression during the second stage of labour?

Answer 48

Changing positions Encouragement Analgesia Oxytocin Episiotomy Instrumental delivery Caesarean section

Question 49

What are the main options for managing failure to progress?

Answer 49

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

Question 50

Skim summary of umbilical cord prolapse:

Answer 50

Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia. Emergency caesarean section is indicated where cord prolapse occurs. A normal vaginal delivery has a high risk of cord compression and significant hypoxia to the baby.

Question 51

Summary of how shoulder dystocia is managed:

Answer 51

Shoulder dystocia is an obstetric emergency and needs to be managed by experienced midwives and obstetricians. The first step is to get help, including anaesthetics and paediatrics. Several techniques can be used to manage the condition and deliver the baby. Episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears. McRoberts manoeuvre involves 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 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.

Question 52

What are the complications of shoulder dystocia?

Answer 52

* Fetal hypoxia (and subsequent cerebral palsy) * Brachial plexus injury and Erb’s palsy * Perineal tears * Postpartum haemorrhage

Question 53

Long term complications of perineal tears:

Answer 53

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

Question 54

Management of the third stage of labour:

Answer 54

Physiological management is where the placenta is delivered by maternal effort without medications or cord traction. Active management of the third stage is where the midwife or doctor assist in delivering of the placenta. It involves a dose of intramuscular oxytocin to help the uterus contract, and careful traction to the umbilical cord to guide the placenta out of the uterus and vagina. Active management shortens the third stage and reduces the risk of bleeding, but can be associated with nausea and vomiting.

Question 55

Skim the steps of active management of the third stage:

Answer 55

Active management of the third stage involves an intramuscular dose of oxytocin (10 IU) after delivery of the baby. The cord is clamped and cut within 5 minutes of birth. There should be a delay of 1 – 3 minutes between delivery of the baby and clamping of the cord to allow blood to flow to the baby (unless the baby needs resuscitation). The abdomen is palpated to assess for a uterine contraction before delivery of the placenta. Controlled cord traction is carefully applied during uterine contractions to help deliver the placenta, stopping if there is resistance. At the same time the other hand presses the uterus upwards (in the opposite direction) to prevent uterine prolapse. The aim is to deliver the placenta in one piece. After delivery the uterus is massaged until it is contracted and firm. The placenta is examined to ensure it is complete and no tissue remains in the uterus.

Question 56

How much blood loss is classed as PPH?

Answer 56

500ml after a vaginal delivery 1000ml after a caesarean section

Question 57

What are the four causes of PPH? 4T's

Answer 57

T – Tone (uterine atony – the most common cause) T – Trauma (e.g. perineal tear) T – Tissue (retained placenta) T – Thrombin (bleeding disorder)

Question 58

How is PPH managed?

Answer 58

Management to stabilise the patient involves: * Resuscitation with an ABCDE approach. * Lie the woman flat, keep her warm and communicate with her and the partner. * Insert two large-bore cannulas. * Bloods for FBC, U&E and clotting screen. * Group and cross match 4 units. * Warmed IV fluid and blood resuscitation as required. * Oxygen (regardless of saturations). * Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion.

Question 59

The treatment options for stopping the PPH bleeding can be categorised as: * Mechanical * Medical * Surgical

Answer 59

The treatment options for stopping the PPH bleeding can be categorised as: * Mechanical * Medical * Surgical

Question 60

Medical and mechanical treatments for PPH:

Answer 60

Mechanical treatment options involve: Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”) Catheterisation (bladder distention prevents uterus contractions) Medical treatment options involve: Oxytocin (slow injection followed by continuous infusion) Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension) Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma) Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding.

Question 61

Surgical interventions for postpartum haemorrhage:

Answer 61

Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding. 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. Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life.

Question 62

Summary of secondary postpartum haemorrhage:

Answer 62

Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis). Investigations involve: Ultrasound for retained products of conception Endocervical and high vaginal swabs for infection Management depends on the cause: Surgical evaluation of retained products of conception Antibiotics for infection

Question 63

What are the two key causes of sepsis in pregnancy?

Answer 63

Chorioamnionitis Urinary tract infections

Question 64

Chorioamnionitis

Answer 64

Chorioamnionitis is an 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.

Question 65

Management of maternal sepsis:

Answer 65

Three tests: * Blood lactate level * Blood cultures * Urine output Three treatments: * Oxygen to maintain oxygen saturations 94-98% * Empirical broad-spectrum antibiotics * IV fluids

Question 66

Uterine rupture (read)

Answer 66

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. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.

Question 67

What is the biggest risk factor of uterine rupture?

Answer 67

The main risk factor for uterine rupture is a previous caesarean section.

Question 68

Presentation of uterine rupture:

Answer 68

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: * Abdominal pain * Vaginal bleeding * Ceasing of uterine contractions * Hypotension * Tachycardia * Collapse

Question 69

Management of uterine rupture:

Answer 69

Uterine rupture is an obstetric emergency. Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Question 70

Placenta accreta

Answer 70

Placenta accreta is a serious pregnancy condition that occurs when the placenta grows too deeply into the uterine wall. Typically, the placenta detaches from the uterine wall after childbirth. With placenta accreta, part or all of the placenta remains attached. This can cause severe blood loss after delivery.

Question 71

Placenta previa

Answer 71

Placenta previa occurs when a baby's placenta partially or totally covers the mother's cervix — the outlet for the uterus. Placenta previa can cause severe bleeding during pregnancy and delivery. If you have placenta previa, you might bleed throughout your pregnancy and during your delivery.

Question 72

Placental abruption

Answer 72

Placental abruption is where a part or all of the placenta separates from the wall of the uterus prematurely. It is an important cause of antepartum haemorrhage – vaginal bleeding from week 24 of gestation until delivery. ## Footnote **Woody uterus**

Question 73

What time period in pregnancy do ectopics usually present?

Answer 73

Ectopic pregnancy typically presents around 6 – 8 weeks gestation. Have a low threshold for suspecting an ectopic pregnancy, even in atypical presentations. Always ask about the possibility of pregnancy, missed periods and recent unprotected sex in women presenting with lower abdominal pain.

Question 74

Classic features of ectopic:

Answer 74

* Missed period * Constant lower abdominal pain in the right or left iliac fossa * Vaginal bleeding * Lower abdominal or pelvic tenderness * Cervical motion tenderness (pain when moving the cervix during a bimanual examination)

Question 75

How is ectopic pregnancy diagnosed?

Answer 75

A transvaginal ultrasound scan is the investigation of choice for diagnosing a miscarriage. A gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube.

Question 76

Management of ectopic pregnancy?

Answer 76

Perform a pregnancy test in all women with abdominal or pelvic pain that may be caused by an ectopic pregnancy. Women with pelvic pain or tenderness and a positive pregnancy test need to be referred to an early pregnancy assessment unit (EPAU) or gynaecology service. **All ectopic pregnancies need to be terminated.** An ectopic pregnancy is not a viable pregnancy. There are three options for terminating an ectopic pregnancy: * Expectant management (awaiting natural termination) * Medical management (methotrexate) * Surgical management (salpingectomy or salpingotomy)

Question 77

Surgical management of ectopic

Answer 77

**Laparoscopic salpingectomy is the first-line** treatment for ectopic pregnancy. This involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube. Laparoscopic salpingotomy may be used in women at increased risk of infertility due to damage to the other tube. The aim is to avoid removing the affected fallopian tube. A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed.

Question 78

Miscarriage

Answer 78

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

Question 79

Inevitable miscarriage

Answer 79

Inevitable miscarriage – vaginal bleeding with an open cervix.

Question 80

Terms of misscarriage

Answer 80

Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive. Inevitable miscarriage – vaginal bleeding with an open cervix. Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage. Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus. Anembryonic pregnancy – a gestational sac is present but contains no embryo.

Question 81

Management of miscarriage of less than 6 weeks:

Answer 81

**Expectant management before 6 weeks gestation** involves awaiting the miscarriage without investigations or treatment.

Question 82

There are three options for managing a miscarriage:

Answer 82

* Expectant management (do nothing and await a spontaneous miscarriage) * Medical management (misoprostol) * Surgical management

Question 83

Expectant miscarriage

Answer 83

Expectant management is 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.

Question 84

Medical management of miscarriage

Answer 84

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions. Medical management of miscarriage involves using a dose of misoprostol to expedite the process of miscarriage. This can be as a vaginal suppository or an oral dose.

Question 85

Side effects of misoprostol:

Answer 85

* Heavier bleeding * Pain * Vomiting * Diarrhoea

Question 86

Surgical management of miscarriage

Answer 86

There are two options for surgical management of a miscarriage: * Manual vacuum aspiration under local anaesthetic as an outpatient * Electric vacuum aspiration under general anaesthetic

Question 87

Incomplete miscarriage

Answer 87

An incomplete miscarriage occurs when retained products of conception (fetal or placental tissue) remain in the uterus after the miscarriage. Retained products create a risk of infection. There are two options for treating an incomplete miscarriage: * Medical management (misoprostol). * Surgical management (evacuation of retained products of conception).

Question 88

Recurrent miscarriage - when are they investigated?

Answer 88

Miscarriage is relatively common. Recurrent miscarriage is classed as three or more consecutive miscarriages. Three or more first-trimester miscarriages One or more second-trimester miscarriages

Question 89

Causes of miscarriage:

Answer 89

Idiopathic (particularly in older women) Antiphospholipid syndrome Hereditary thrombophilias Uterine abnormalities Genetic factors in parents (e.g. balanced translocations in parental chromosomes) Chronic histiocytic intervillositis Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)

Question 90

Antiphospholipid syndrome and miscarriage

Answer 90

Antiphospholipid syndrome is a disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting. The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage. Antiphospholipid syndrome can occur on its own, or secondary to an autoimmune condition such as systemic lupus erythematosus.

Question 91

Top tip:

Answer 91

If you remember one cause of recurrent miscarriages, remember antiphospholipid syndrome. Consider this in patients presenting in exams with recurrent miscarriages. There may be a past history of deep vein thrombosis. Test for antiphospholipid antibodies, and treatment is with aspirin and LMWH.

Question 92

Investigations for recurrent miscarriage:

Answer 92

Antiphospholipid antibodies Testing for hereditary thrombophilias Pelvic ultrasound Genetic testing of the products of conception from the third or future miscarriages Genetic testing on parents

Question 93

Hydatidiform mole

Answer 93

A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy. There are two types of molar pregnancy: a complete mole and a partial mole.

Question 94

A complete mole

Answer 94

A 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.

Question 95

A partial mole

Answer 95

A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.

Question 96

How to identify molar pregnancy vs normal pregnancy:

Answer 96

More severe morning sickness Vaginal bleeding Increased enlargement of the uterus Abnormally high hCG Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)

Question 97

How is a molar pregnancy diagnosed?

Answer 97

Ultrasound of the pelvis shows a characteristic “**snowstorm appearance**” of the pregnancy. Provisional diagnosis can be made by ultrasound and confirmed with histology of the mole after evacuation.

Question 98

How is molar pregnancy managed?

Answer 98

Management involves evacuation of the uterus to remove the mole. The products of conception need to be sent for histological examination to confirm a molar pregnancy. 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 99

What is the latest gestational age where an abortion is legal?

Answer 99

24 weeks

Question 100

Medication abortion involves what treatments?

Answer 100

Mifepristone (anti-progestogen) Misoprostol (prostaglandin analogue) 1 – 2 day later

Question 101

Explaination of medical termination of pregnancy:

Answer 101

Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix. Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions. From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion. Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.

Question 102

Nausea and vomiting in pregnancy starts in the first trimester, peaking around what time?

Answer 102

8 – 12 weeks gestation.

Question 103

Hyperemesis gravidum

Answer 103

Hyper- refers to lots, -emesis refers to vomiting and gravida- relates to pregnancy.

Question 104

What is thought to cause hyperemesis gravidum?

Answer 104

The placenta produces human chorionic gonadotropin (hCG) during pregnancy. This hormone is thought to be responsible for nausea and vomiting. 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.

Question 105

Guidelines for diagnosis of hyperemesis gravidum:

Answer 105

More than 5 % weight loss compared with before pregnancy Dehydration Electrolyte imbalance

Question 106

How is Hyperemesis gravidum managed?

Answer 106

Antiemetics are used to suppress nausea. Vaguely in order of preference and known safety, the choices are: 1. Prochlorperazine (stemetil) 2. Cyclizine 3. Ondansetron 4. Metoclopramide

Question 107

When should one be admitted with hyperemesis gravidum?

Answer 107

Mild cases can be managed with oral antiemetics at home. Admission should be considered when: * Unable to tolerate oral antiemetics or keep down any fluids * More than 5 % weight loss compared with pre-pregnancy * Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant) * Other medical conditions need treating that required admission

Question 108

Moderate-severe cases may require ambulatory care (e.g. early pregnancy assessment unit) or admission for: Management of severe cases...?

Answer 108

* IV or IM antiemetics * IV fluids (normal saline with added potassium chloride) * Daily monitoring of U&Es while having IV therapy * Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome) * Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission

Question 109

Presentation of placental abruption:

Answer 109

Placental abruption typically presents with painful vaginal bleeding (bleeding may not be visible if it is concealed). If the woman is in labour, inquire about pain between contractions. On examination, the uterus may be woody (tense all of the time) and painful on palpation.

Question 110

Vaginal bleeding with open cervix =

Answer 110

Inevitable misscarriage

Question 111

Most likely site of an ectopic?

Answer 111

Ampulla of fallopian tube

Question 112

Brain bleeds in babies?

Answer 112

IVH in premature infants, Subdural Haematoma in Shaken Baby Syndrome.