Zero To Finals - Obstetrics

Question 1

Trimesters

Answer 1

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

It is worth noting that fetal movements start from around 20 weeks gestation, and continue until birth.

Question 2

Importance of folate in pregnancy

Answer 2

Folate
Important for cell division and growth

Give 400micrograms daily during preconception and 1st trimester
Higher risk pregnancies get folic acid 5mg OD:
• Taking anti-epileptics
• Have a neural tube defect in mother/father
• Mothered a previous child with a neural tube defect
• DM
• Sickle cell disease

Question 3

Combined test for Down syndrome

Answer 3

Combined Test
The combined test is the first line and the most accurate screening test.
It is performed between 11 and 14 weeks gestation and involves combining results from ultrasound and maternal blood tests.
1. Ultrasound measures nuchal translucency, which is the thickness of the back of the neck of the fetus.
a. Down’s syndrome is one cause of a nuchal thickness greater than 6mm.
2. Maternal blood tests:
○ Beta‑human chorionic gonadotrophin (beta-HCG) – a higher result indicates a greater risk
○ Pregnancy‑associated plasma protein‑A (PAPPA) – a lower result indicates a greater risk

Question 4

Antenatal testing for Down syndrome

Answer 4

§ The screening tests provide a risk score for the fetus having Down’s syndrome.
§ When the risk of Down’s is greater than 1 in 150 (occurs in around 5% of tested women), the woman is offered amniocentesis or chorionic villus sampling.

Question 5

Non invasive pre natal testing

Answer 5

Non-Invasive Prenatal Testing
• Non-invasive prenatal testing (NIPT) is a relatively new test for detecting abnormalities in the fetus during pregnancy.
• It involves a simple blood test from the mother.
• 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.
• NIPT is gradually being rolled out in the NHS as an alternative to invasive testing (CVS and amniocentesis) for women that have a higher than 1 in 150 risk of Down’s syndrome.

Question 6

Hypothyroidism in pregnancy

Answer 6

Hypothyroidism in Pregnancy
• Untreated or under-treated hypothyroidism in pregnancy can lead to several adverse pregnancy outcomes, including miscarriage, anaemia, small for gestational age and pre-eclampsia.
• Hypothyroidism is treated with levothyroxine (T4).
• Levothyroxine can cross the placenta and provide thyroid hormone to the developing fetus.
• The levothyroxine dose needs to be increased during pregnancy, usually by at least 25 – 50 mcg (30 – 50%).
• Treatment is titrated based on the TSH level, aiming for a low-normal TSH level.

Question 7

Hypertension in pregnancy

Answer 7

Hypertension
Women with existing hypertension may need changes to their medications.
Medications that should be stopped as they may cause congenital abnormalities:
• ACE inhibitors (e.g. ramipril)
• Angiotensin receptor blockers (e.g. losartan)
• Thiazide and thiazide-like diuretics (e.g. indapamide)

Medications that are not known to be harmful:
• Labetalol (a beta-blocker – although other beta-blockers may have adverse effects)
• Calcium channel blockers (e.g. nifedipine)
• Methyldopa

Target BP if hypertensive before pregnancy is 135/85

Question 8

Sickle cell disease in pregnancy

Answer 8

Sickle Cell Disease
• Should take aspirin from 12 weeks of pregnancy
• Screen for trait in mother and if present check the father

Question 9

HIV in pregnancy

Answer 9

HIV
• Start highly active antiretroviral treatment at 24 weeks
• Screen for hep B/C
• Usually delivered by caesarean to reduce vertical transmission
○ Unless have very low CD4 viral load
• Avoid breast feeding

Question 10

Epilepsy in pregnancy

Answer 10

Epilepsy in Pregnancy
§ Women with epilepsy should take folic acid 5mg daily from before conception to reduce the risk of neural tube defects.
§ Pregnancy may worsen seizure control due to the additional stress, lack of sleep, hormonal changes and altered medication regimes.
§ Seizures are not known to be harmful to the pregnancy, other than the risk of physical injury.
§ Ideally, epilepsy should be controlled with a single anti-epileptic drug before becoming pregnant.

Regarding anti-epileptic drugs:
§ Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medication in pregnancy

Question 11

Rheumatoid arthritis in pregnancy

Answer 11

Rheumatoid Arthritis
□ Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa.
□ It is an inflammatory arthritis.
□ It is treated with disease-modifying anti-rheumatic drugs (DMARDs).
□ Ideally, rheumatoid arthritis should be well controlled for at least three months before becoming pregnant.
□ Often the symptoms of rheumatoid arthritis will improve during pregnancy, and may flare up after delivery.

The treatment regime may need to be altered by a specialist rheumatologist before and during pregnancy:
□ Methotrexate is contraindicated, and is teratogenic, causing miscarriage and congenital abnormalities
□ Hydroxychloroquine is considered safe during pregnancy and is often the first-line choice
□ Sulfasalazine is considered safe during pregnancy
□ Corticosteroids may be used during flare-ups

Question 12

NSAID’s in pregnancy

Answer 12

Non-Steroidal Anti-Inflammatory Drugs
E.g. ibuprofen and naproxen.

• 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 13

Beta blockers in pregnancy

Answer 13

Beta-Blockers
Beta-blockers are commonly used for hypertension, cardiac conditions and migraine.
Labetalol is the most frequently used beta-blocker in pregnancy, and is first-line for high blood pressure caused by pre-eclampsia.

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

Question 14

ACE Inhibitors and ARBs in pregnancy

Answer 14

ACE Inhibitors and Angiotensin II Receptor Blockers
○ Medications that 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).
○ The other notably effect is hypocalvaria, which is an incomplete formation of the skull bones.

ACE inhibitors and ARBs, when used in pregnancy, can cause:
○ Oligohydramnios (reduced amniotic fluid)
○ Miscarriage or fetal death
○ Hypocalvaria (incomplete formation of the skull bones)
○ Renal failure in the neonate
○ Hypotension in the neonate

Question 15

Opiate use in pregnancy

Answer 15

Opiates
• The use of opiates during pregnancy can cause withdrawal symptoms in the neonate after birth.
• This is called neonatal abstinence syndrome (NAS).
• NAS presents between 3 – 72 hours after birth with irritability, tachypnoea (fast breathing), high temperatures and poor feeding.

Question 16

Antibiotic use in pregnancy

Answer 16

Antibiotics
1st line = penicillins + cephalosporins

Avoid tetracyclines in 2nd + 3rd trimester - risk to bone and tooth development
Avoid nitrofurantoin in 3rd trimester - risk of haemolytic anaemia in newborn

Question 17

Warfarin and pregnancy

Answer 17

Warfarin
Warfarin may be used in younger patients with recurrent venous thrombosis, atrial fibrillation or metallic mechanical heart valves.
It crosses the placenta and is considered teratogenic in pregnancy, therefore it is avoided in pregnant women.
Warfarin can cause:
§ Fetal loss
§ Congenital malformations, particularly craniofacial problems
§ Bleeding during pregnancy, postpartum haemorrhage, fetal haemorrhage and intracranial bleeding

Question 18

Lithium in pregnancy

Answer 18

Lithium
Lithium is used as a mood stabilising medication for patients with bipolar disorder, mania and recurrent depression.
It is avoided in pregnant women or those planning pregnancy unless other options (i.e. antipsychotics) have failed.

• Lithium is particularly avoided in the first trimester, as this is linked with congenital cardiac abnormalities. 
	○ In particular, it is associated with Ebstein’s anomaly, where the tricuspid valve is set lower on the right side of the heart (towards the apex), causing a bigger right atrium and a smaller right ventricle.
• When lithium is used, levels need to be monitored closely (NICE says every four weeks, then weekly from 36 weeks). 
• Lithium also enters breast milk and is toxic to the infant, so should be avoided in breastfeeding.

Question 19

SSRI’s in pregnancy

Answer 19

Selective Serotonin Reuptake Inhibitors
Selective serotonin reuptake inhibitors (SSRIs) are the most commonly used antidepressants in pregnancy.
□ SSRIs can cross the placenta into the fetus.
□ The risks need to be balanced against the benefits of treatment.
□ The risks associated with untreated depression can be very significant.

Women need to be aware of the potential risks of SSRIs in pregnancy:
□ First-trimester use has a link with congenital heart defects
□ First-trimester use of paroxetine has a stronger link with congenital malformations
□ Third-trimester use has a link with persistent pulmonary hypertension in the neonate
□ Neonates can experience withdrawal symptoms, usually only mild and not requiring medical management

Question 20

Roaccutane in pregnancy

Answer 20

Isotretinoin (Roaccutane)
Isotretinoin is a retinoid medication (relating to vitamin A) that is used to treat severe acne.
It should be prescribed and monitored by a specialist dermatologist.

• Isotretinoin is highly teratogenic, causing miscarriage and congenital defects. 
• Women need very reliable contraception before, during and for one month after taking isotretinoin.

Question 21

Rubella in pregnancy

Answer 21

Rubella
• Rubella is also known as German measles.
• 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.
• 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.

The features of congenital rubella syndrome to be aware of are:
• Congenital deafness
• Congenital cataracts
• Congenital heart disease (PDA and pulmonary stenosis)
• Learning disability

Question 22

Chicken pox in pregnancy

Answer 22

Chickenpox
Chickenpox is caused by the varicella zoster virus (VZV).
It is dangerous in pregnancy because it can lead to:
○ More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis
○ Fetal varicella syndrome
○ Severe neonatal varicella infection (if infected around delivery)

Mothers that have previously had chickenpox are immune and safe.
○ When in doubt, IgG levels for VZV can be tested. A positive IgG for VZV indicates immunity.
○ Women that are not immune to varicella may be offered the varicella vaccine before or after pregnancy.

Exposure to chickenpox in pregnancy:
○ When the pregnant woman has previously had chickenpox, they are safe
○ When they are not sure about their immunity, test the VZV IgG levels. If positive, they are safe.
○ When they are not immune, they can be treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox. This should be given within ten days of exposure.

When the chickenpox rash starts in pregnancy, they may be treated with oral aciclovir if they present within 24 hours and are more than 20 weeks gestation.

Question 23

Listeria infection in pregnancy

Answer 23

Listeria
• Listeria is an infectious gram-positive bacteria that causes listeriosis.
• Listeriosis is many times more likely in pregnant women compared with non-pregnant individuals.
• Infection in the mother may be asymptomatic, cause a flu-like illness, or less commonly cause pneumonia or meningoencephalitis.
• Listeriosis in pregnant women has a high rate of miscarriage or fetal death. It can also cause severe neonatal infection.
• Listeria is typically transmitted by unpasteurised dairy products, processed meats and contaminated foods.
• Pregnant women are advised to avoid high-risk foods (e.g. blue cheese) and practice good food hygiene.

Question 24

Congenital cytomegalovirus in pregnancy

Answer 24

Congenital Cytomegalovirus
® Congenital cytomegalovirus infection occurs due to a cytomegalovirus (CMV) infection in the mother during pregnancy.
® The virus is mostly spread via the infected saliva or urine of asymptomatic children.
® Most cases of CMV in pregnancy do not cause congenital CMV.

The features of congenital CMV are:
® Fetal growth restriction
® Microcephaly
® Hearing loss
® Vision loss
® Learning disability
® Seizures

Question 25

Congenital toxoplasmosis in pregnancy

Answer 25

Congenital Toxoplasmosis ◊ Infection with the Toxoplasma gondii parasite is usually asymptomatic. ◊ It is primarily spread by contamination with faeces from a cat that is a host of the parasite. ◊ When infection occurs during pregnancy, it can lead to congenital toxoplasmosis. ◊ The risk is higher later in the pregnancy. There is a classic triad of features in congenital toxoplasmosis: ◊ Intracranial calcification ◊ Hydrocephalus ◊ Chorioretinitis (inflammation of the choroid and retina in the eye)

Question 26

Parovirus B19 in pregnancy

Answer 26

Infections with parvovirus B19 in pregnancy can lead to several complications, particularly in the first and second trimesters. Complications are: } Miscarriage or fetal death } Severe fetal anaemia } Hydrops fetalis (fetal heart failure) } Maternal pre-eclampsia-like syndrome Fetal anaemia is caused by parvovirus infection of the erythroid progenitor cells in the fetal bone marrow and liver. } These cells produce red blood cells, and the infection causes them to produce faulty red blood cells that have a shorter life span. } Less red blood cells results in anaemia. } This anaemia leads to heart failure, referred to as hydrops fetalis. Maternal pre-eclampsia-like syndrome is also known as mirror syndrome. } It can be a rare complication of severe fetal heart failure (hydrops fetalis). } It involves a triad of hydrops fetalis, placental oedema and oedema in the mother. } It also features hypertension and proteinuria. Women suspected of parvovirus infection need tests for: } IgM to parvovirus, which tests for acute infection within the past four weeks } IgG to parvovirus, which tests for long term immunity to the virus after a previous infection } Rubella antibodies (as a differential diagnosis) Treatment is supportive. Women with parvovirus B19 infection need a referral to fetal medicine to monitor for complications and malformations.

Question 27

Zika virus in pregnancy

Answer 27

Zika Virus w The zika virus is spread by host Aedes mosquitos in areas of the world where the virus is prevalent. w It can also be spread by sex with someone infected with the virus. w It can cause no symptoms, minimal symptoms, or a mild flu-like illness. In pregnancy, it can lead to congenital Zika syndrome, which involves: w Microcephaly w Fetal growth restriction w Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy Pregnant women that may have contracted the Zika virus should be tested with viral PCR and antibodies to the Zika virus. w Women with a positive result should be referred to fetal medicine for close monitoring of the pregnancy. There is no treatment for the virus.

Question 28

Rhesus incompatibility in pregnancy

Answer 28

Rhesus Incompatibility in Pregnancy • Women that are rhesus-D positive do not need any additional treatment during pregnancy. • When a woman that is rhesus-D negative becomes pregnant, we have to consider the possibility that her child will be rhesus positive. • It is likely at some point in the pregnancy (i.e. childbirth) that the 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. • Usually, this sensitisation process does not cause problems during the first pregnancy. • During subsequent pregnancies, the mother’s anti-rhesus-D antibodies can cross the placenta into the fetus. • 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 29

Anti D injections

Answer 29

Management Prevention of sensitisation is the mainstay of management. • This involves giving intramuscular anti-D injections to rhesus-D negative women. • There is no way to reverse the sensitisation process once it has occurred, which is why prophylaxis is so essential. • The anti-D medication works by attaching itself to the rhesus-D antigens on the fetal red blood cells in the mothers circulation, causing them to be destroyed. • This prevents the mother’s immune system recognising the antigen and creating it’s own antibodies to the antigen. • It acts as a prevention for the mother becoming sensitised to the rhesus-D antigen. Anti-D injections are given routinely on two occasions: • 28 weeks gestation • Birth (if the baby’s blood group is found to be rhesus-positive) Anti-D injections should also be given at any time where sensitisation may occur, such as: • Antepartum haemorrhage • Amniocentesis procedures • Abdominal trauma Anti-D is given within 72 hours of a sensitisation event. After 20 weeks gestation, the Kleinhauer test is performed to see how much fetal blood has passed into the mother’s blood, to determine whether further doses of anti-D are required.

Question 30

When should a couple be referred for further testing regarding infertility?

Answer 30

Investigation and referral for infertility should be initiated after the couple has been trying to conceive without success for 12 months. This can be reduced to 6 months if the woman is older than 35, as her ovarian stores are likely to be already reduced and time is more precious.

Question 31

Some causes of infertility

Answer 31

Causes • Sperm problems (30%) • Ovulation problems (25%) • Tubal problems (15%) • Uterine problems (10%) • Unexplained (20%) 40% of infertile couples have a mix of male and female causes.

Question 32

Female hormone testing for infertility

Answer 32

Female hormone testing involves: • Serum LH and FSH on day 2 to 5 of the cycle • Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle). • Anti-Mullerian hormone • Thyroid function tests when symptoms are suggestive • Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development. High LH may suggest polycystic ovarian syndrome (PCOS). A rise in progesterone on day 21 indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone. Anti-Mullerian hormone can be measured at any time during the cycle and is the most accurate marker of ovarian reserve. It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve. Further investigations, often performed in secondary care: ○ Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus ○ Hysterosalpingogram to look at the patency of the fallopian tubes ○ Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis

Question 33

What is Hysterosalpingogram

Answer 33

Hysterosalpingogram A hysterosalpingogram is a type of scan used to assess the shape of the uterus and the patency of the fallopian tubes. Not only does it help with diagnosis, but it also has therapeutic benefit. It seems to increase the rate of conception without any other intervention. Tubal cannulation under xray guidance can be performed during the procedure to open up the tubes. A small tube is inserted into the cervix. A contrast medium is injected through the tube and fills the uterine cavity and fallopian tubes. Xray images are taken, and the contrast shows up on the xray giving an outline of the uterus and tubes. If the dye does not fill one of the tubes, this will be seen on an xray and suggests a tubal obstruction. There is a risk of infection with the procedure, and often antibiotics are given prophylactically for patients with dilated tubes or a history of pelvic infection. Screening for chlamydia and gonorrhoea should be done before the procedure.

Question 34

Management when anovulation is the cause of infertility

Answer 34

The options when anovulation is the cause of infertility include: • Weight loss for overweight patients with PCOS can restore ovulation • Clomifene may be used to stimulate ovulation • Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects) • Gonadotropins may be used to stimulate ovulation in women resistant to clomifene • Ovarian drilling may be used in polycystic ovarian syndrome • Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS) Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH. Ovarian drilling involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.

Question 35

Management of tubal factors affecting fertility

Answer 35

Management of Tubal Factors The options for women with alterations to the fallopian tubes that prevent the ovum from reaching the sperm and uterus include: • Tubal cannulation during a hysterosalpingogram • Laparoscopy to remove adhesions or endometriosis • In vitro fertilisation (IVF)

Question 36

Management of uterine factors affecting fertility

Answer 36

Management of Uterine Factors Surgery may be used to correct polyps, adhesions or structural abnormalities affecting fertility.

Question 37

Management of sperm problems affecting fertility

Answer 37

Management of Sperm Problems 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 38

What factors can affect semen analysis

Answer 38

Factors Affecting Semen Analysis and Sperm Quality and Quantity Several lifestyle factors may affect the results of semen analysis and the quality and quantity of sperm: • Hot baths • Tight underwear • Smoking • Alcohol • Raised BMI • Caffeine A repeat sample is indicated after 3 months in borderline results or earlier (2 – 4 weeks) with very abnormal results.

Question 39

Results of semen analysis

Answer 39

Results Normal results indicated by the World Health Organisation are: • Semen volume (more than 1.5ml) • Semen pH (greater than 7.2) • Concentration of sperm (more than 15 million per ml) • Total number of sperm (more than 39 million per sample) • Motility of sperm (more than 40% of sperm are mobile) • Vitality of sperm (more than 58% of sperm are active) • Percentage of normal sperm (more than 4%) Polyspermia (or polyzoospermia) refers to a high number of sperm in the semen sample (more than 250 million per ml). Normospermia (or normozoospermia) refers to normal characteristics of the sperm in the semen sample. Oligospermia (or oligozoospermia) is a reduced number of sperm in the semen sample. It is classified as: ○ Mild oligospermia (10 to 15 million / ml) ○ Moderate oligospermia (5 to 10 million / ml) ○ Severe oligospermia (less than 5 million / ml) Cryptozoospermia refers to very few sperm in the semen sample (less than 1 million / ml). Azoospermia is the absence of sperm in the semen.

Question 40

Pre testicular causes of low sperm

Answer 40

Pre-Testicular Causes Testosterone is necessary for sperm creation. The hypothalamo-pituitary-gonadal axis controls testosterone. Hypogonadotrophic hypogonadism (low LH and FSH resulting in low testosterone), can be due to: • Pathology of the pituitary gland or hypothalamus • Suppression due to stress, chronic conditions or hyperprolactinaemia • Kallman syndrome

Question 41

Testicular causes of low sperm count

Answer 41

Testicular Causes Testicular damage from: • Mumps • Undescended testes • Trauma • Radiotherapy • Chemotherapy • Cancer Genetic or congenital disorders that result in defective or absent sperm production, such as: ○ Klinefelter syndrome ○ Y chromosome deletions ○ Sertoli cell-only syndrome ○ Anorchia (absent testes)

Question 42

Post testicular causes of low sperm count

Answer 42

Post-Testicular Causes Obstruction preventing sperm being ejaculated can be caused by: § Damage to the testicle or vas deferens from trauma, surgery or cancer § Ejaculatory duct obstruction § Retrograde ejaculation § Scarring from epididymitis, for example, caused by chlamydia § Absence of the vas deferens (may be associated with cystic fibrosis) § Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)

Question 43

Investigations following abnormal semen analysis

Answer 43

Investigations The initial steps for investigating abnormal semen analysis include a history, examination, repeat sample and ultrasound of the testes. Patients with abnormal semen results are referred to a urologist for further investigations. Further investigations that may be considered include: • Hormonal analysis with LH, FSH and testosterone levels • Genetic testing • Further imaging, such as transrectal ultrasound or MRI • Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction • Testicular biopsy

Question 44

Management of male factor infertility

Answer 44

Management Management depends on the underlying cause, and can involve: • Surgical sperm retrieval where there is obstruction • Surgical correction of an obstruction in the vas deferens • Intra-uterine insemination involves separating high-quality sperm, then injecting them into the uterus • Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg • Donor insemination involves sperm from a donor

Question 45

Process of IVF

Answer 45

Process There are a number of steps involved in the process of IVF: • Suppressing the natural menstrual cycle • Ovarian stimulation • Oocyte collection • Insemination / intracytoplasmic sperm injection (ICSI) • Embryo culture • Embryo transfer

Question 46

Complications of IVF

Answer 46

Complications The main complications relating to the overall process are: • Failure • Multiple pregnancy • Ectopic pregnancy • Ovarian hyperstimulation syndrome There is a small risk of complications relating to the egg collection procedure: • Pain • Bleeding • Pelvic infection • Damage to the bladder or bowel

Question 47

What is ovarian hyperstimulation syndrome

Answer 47

Ovarian hyperstimulation syndrome (OHSS) is a complication of ovarian stimulation during IVF infertility treatment. It is associated with the use of human chorionic gonadotropin (hCG) to mature the follicles during the final steps of ovarian stimulation.

Question 48

Pathophysiology of ovarian hyper stimulation syndrome

Answer 48

Pathophysiology The primary mechanism for OHSS is an increase in vascular endothelial growth factor (VEGF) released by the granulosa cells of the follicles. VEGF increases vascular permeability, causing fluid to leak from capillaries. Fluid moves from the intravascular space to the extravascular space. This results in oedema, ascites and hypovolaemia. The use of gonadotrophins (LH and FSH) during ovarian stimulation results in the development of multiple follicles. OHSS is provoked by the “trigger injection” of hCG 36 hours before oocyte collection. HCG stimulates the release of VEGF from the follicles. The features of the condition begin to develop after the hCG injection. There is also activation of the renin-angiotensin system. A notable finding in patients with OHSS is a raised renin level. The renin level correlates with the severity of the condition.

Question 49

How is development of ovarian hyperstimulation syndrome tried to be prevented?

Answer 49

Prevention Women are individually assessed for their risk of developing OHSS. During stimulation with gonadotrophins, they are monitored with: • Serum oestrogen levels (higher levels indicate a higher risk) • Ultrasound monitor of the follicles (higher number and larger size indicate a higher risk) In women at higher risk several strategies may be used to reduce the risk: ○ Use of the GnRH antagonist protocol (rather than the GnRH agonist protocol) ○ Lower doses of gonadotrophins ○ Lower dose of the hCG injection ○ Alternatives to the hCG injection (i.e. a GnRH agonist or LH)

Question 50

Risk factors for getting ovarian hyperstimulation syndrome

Answer 50

Risk Factors • Younger age • Lower BMI • Raised anti-Müllerian hormone • Higher antral follicle count • Polycystic ovarian syndrome • Raised oestrogen levels during ovarian stimulation

Question 51

Features and symptoms of ovarian hyperstimulation syndrome

Answer 51

Features Early OHSS presents within 7 days of the hCG injection. Late OHSS presents from 10 days onwards. Features of the condition include: • Abdominal pain and bloating • Nausea and vomiting • Diarrhoea • Hypotension • Hypovolaemia • Ascites • Pleural effusions • Renal failure • Peritonitis from rupturing follicles releasing blood • Prothrombotic state (risk of DVT and PE)

Question 52

Severity of ovarian hyperstimulation syndrome

Answer 52

Severity The severity is determined based on the clinical features: • Mild: Abdominal pain and bloating • Moderate: Nausea and vomiting with ascites seen on ultrasound • Severe: Ascites, low urine output (oliguria), low serum albumin, high potassium and raised haematocrit (>45%) • Critical: Tense ascites, no urine output (anuria), thromboembolism and acute respiratory distress syndrome (ARDS)

Question 53

Management of ovarian hyper stimulation syndrome

Answer 53

Management Management is supportive with treatment of any complications. This involves: • Oral fluids • Monitoring of urine output • Low molecular weight heparin (to prevent thromboembolism) • Ascitic fluid removal (paracentesis) if required • IV colloids (e.g. human albumin solution) Patients with mild to moderate OHSS are often managed as an outpatient. Severe cases require admission, and critical cases may require admission to the intensive care unit (ICU). TOM TIP: Haematocrit may be monitored to assess the volume of fluid in the intravascular space. Haematocrit is the concentration of red blood cells in the blood. When the haematocrit goes up, this indicates less fluid in the intravascular space, as the blood is becoming more concentrated. Raised haematocrit can indicate dehydration.

Question 54

What is an ectopic pregnancy?

Answer 54

Ectopic pregnancy is when a pregnancy is implanted outside the uterus. The most common site is a fallopian tube. An ectopic pregnancy can also implant in the entrance to the fallopian tube (cornual region), ovary, cervix or abdomen.

Question 55

Risk factors of having an ectopic pregnancy

Answer 55

Risk Factors Certain factors can increase the risk of ectopic pregnancy: • Previous ectopic pregnancy • Previous pelvic inflammatory disease • Previous surgery to the fallopian tubes • Intrauterine devices (coils) • Older age • Smoking

Question 56

Presentation of an ectopic pregnancy

Answer 56

Presentation 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. The classic features of an ectopic pregnancy include: • 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) It is also worth asking about: ○ Dizziness or syncope (blood loss) ○ Shoulder tip pain (peritonitis)

Question 57

Ultrasound findings of an ectopic pregnancy

Answer 57

Ultrasound Findings 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. Sometimes a non-specific mass may be seen in the tube. When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign” (all referring to the same appearance). A mass representing a tubal ectopic pregnancy moves separately to the ovary. The mass may look similar to a corpus luteum; however, a corpus luteum will move with the ovary. Features that may also indicate an ectopic pregnancy are: • An empty uterus • Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)

Question 58

Criteria for expectant management in an ectopic pregnancy

Answer 58

Criteria for expectant management: ○ Follow up needs to be possible to ensure successful termination ○ The ectopic needs to be unruptured ○ Adnexal mass < 35mm ○ No visible heartbeat ○ No significant pain ○ HCG level < 1500 IU / l Women with expectant management need careful follow up with close monitoring of hCG levels, and quick and easy access to services if their condition changes.

Question 59

Types of management for an ectopic pregnancy

Answer 59

There are three options for terminating an ectopic pregnancy: • Expectant management (awaiting natural termination) • Medical management (methotrexate) • Surgical management (salpingectomy or salpingotomy)

Question 60

Medical management of an ectopic pregnancy

Answer 60

Management with Methotrexate Methotrexate is highly teratogenic (harmful to pregnancy). It is given as an intramuscular injection into a buttock. This halts the progress of the pregnancy and results in spontaneous termination. Women treated with methotrexate are advised not to get pregnant for 3 months following treatment. This is because the harmful effects of methotrexate on pregnancy can last this long. Common side effects of methotrexate include: • Vaginal bleeding • Nausea and vomiting • Abdominal pain • Stomatitis (inflammation of the mouth) Criteria for methotrexate are the same as expectant management, except: § HCG level must be < 5000 IU / l § Confirmed absence of intrauterine pregnancy on ultrasound

Question 61

When is surgery used for an ectopic pregnancy

Answer 61

Surgical Management Anyone that does not meet the criteria for expectant or medical management requires surgical management. Most patients with an ectopic pregnancy will require surgical management. This include those with: • Pain • Adnexal mass > 35mm • Visible heartbeat • HCG levels > 5000 IU / l

Question 62

Two surgical options for an ectopic pregnancy

Answer 62

There are two options for surgical management of ectopic pregnancy: ○ Laparoscopic salpingectomy ○ Laparoscopic salpingotomy 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. There is an increased risk of failure to remove the ectopic pregnancy with salpingotomy compared with salpingectomy. NICE state up to 1 in 5 women having salpingotomy may need further treatment with methotrexate or salpingectomy. Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy.

Question 63

Early vs late miscarriage

Answer 63

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 64

Missed miscarriage

Answer 64

• Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred

Question 65

Threatened miscarriage

Answer 65

• Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive

Question 66

Inevitable miscarriage

Answer 66

• Inevitable miscarriage – vaginal bleeding with an open cervix

Question 67

Incomplete miscarriage

Answer 67

• Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage

Question 68

Complete miscarriage

Answer 68

• Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus

Question 69

Anembryonic pregnancy

Answer 69

• Anembryonic pregnancy – a gestational sac is present but contains no embryo

Question 70

Diagnosing a miscarriage

Answer 70

TV scan is gold standard method. There are three key features that the sonographer looks for in an early pregnancy. These appear sequentially as the pregnancy develops. As each appears, the previous feature becomes less relevant in assessing the viability of the pregnancy. These features are: • Mean gestational sac diameter • Fetal pole and crown-rump length • 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.

Question 71

Management of miscarriage less than 6 weeks gestation

Answer 71

Management Less Than 6 Weeks Gestation Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be managed expectantly provided they have no pain and no other complications or risk factors (e.g. previous ectopic). Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment. An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen. A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed. When bleeding continues, or pain occurs, referral and further investigation is indicated.

Question 72

Management of a miscarriage more than 6 weeks gestation

Answer 72

More Than 6 Weeks Gestation The NICE guidelines (2019) suggest referral to an early pregnancy assessment service (EPAU) for women with a positive pregnancy test (more than 6 weeks’ gestation) and bleeding. The early pregnancy assessment unit will arrange an ultrasound scan. Ultrasound will confirm the location and viability of the pregnancy. It is essential always to consider and exclude an ectopic pregnancy. There are three options for managing a miscarriage: • Expectant management (do nothing and await a spontaneous miscarriage) • Medical management (misoprostol) • Surgical management

Question 73

Expectant management of a miscarriage

Answer 73

Expectant Management 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. Persistent or worsening bleeding requires further assessment and repeat ultrasound, as this may indicate an incomplete miscarriage and require additional management.

Question 74

Medical management of a miscarriage

Answer 74

Medical Management 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. The key side effects of misoprostol are: • Heavier bleeding • Pain • Vomiting • Diarrhoea

Question 75

Surgical management of a miscarriage

Answer 75

Surgical Management Surgical management can be performed under local or general anaesthetic. 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 Prostaglandins (misoprostol) are given before surgical management to soften the cervix. Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage. Manual vacuum aspiration involves a local anaesthetic applied to the cervix. A tube attached to a specially designed syringe is inserted through the cervix into the uterus. The person performing the procedure then manually uses the syringe to aspirate contents of the uterus. To consider manual vacuum aspiration, women must find the process acceptable and be below 10 weeks gestation. It is more appropriate for women that have previously given birth (parous women). Electric vacuum aspiration is the traditional surgical management of miscarriage. It involves a general anaesthetic. The operation is performed through the vagina and cervix without any incisions. The cervix is gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.

Question 76

What is a recurrent miscarriage

Answer 76

Three or more consecutive miscarriage

Question 77

Causes of recurrent miscarriages

Answer 77

Causes • 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 78

Anti phospholipid syndrome

Answer 78

Antiphospholipid Syndrome 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. The risk of miscarriage in patients with antiphospholipid syndrome is reduced by using both: • Low dose aspirin • Low molecular weight heparin (LMWH) TOM TIP: 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 79

Hereditary thrombophillias likely to cause recurrent miscarriage

Answer 79

Hereditary Thrombophilias The key inherited thrombophilias to remember are: • Factor V Leiden (most common) • Factor II (prothrombin) gene mutation • Protein S deficiency

Question 80

Uterine abnormalities which can cause recurrent miscarriage

Answer 80

Uterine Abnormalities Several uterine abnormalities can cause recurrent miscarriages: • Uterine septum (a partition through the uterus) • Unicornuate uterus (single-horned uterus) • Bicornuate uterus (heart-shaped uterus) • Didelphic uterus (double uterus) • Cervical insufficiency • Fibroids

Question 81

Chronic Histiocytic Intervillositis

Answer 81

Chronic Histiocytic Intervillositis Chronic histiocytic intervillositis is a rare cause of recurrent miscarriage, particularly in the second trimester. It can also lead to intrauterine growth restriction (IUGR) and intrauterine death. The condition is poorly understood. Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes. It is diagnosed by placental histology showing infiltrates of mononuclear cells in the intervillous spaces.

Question 82

Investigations following recurrent miscarriage

Answer 82

Investigations Patients should be referred to a specialist in recurrent miscarriage for further investigation. Investigations include: • 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 83

Management of recurrent miscarriage

Answer 83

Management Management of recurrent miscarriage depends on the underlying cause. There is new evidence from the PRISM trial that suggests a benefit to using vaginal progesterone pessaries during early pregnancy for women with recurrent miscarriages presenting with bleeding. This may become part of guidelines in the future. At present, the RCOG guidelines on recurrent miscarriage (2011) state there is insufficient evidence for progesterone supplementation.

Question 84

Medical abortion method

Answer 84

Medical Abortion A medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments: • Mifepristone (anti-progestogen) • Misoprostol (prostaglandin analogue) 1 – 2 day later 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 85

Surgical abortion method

Answer 85

Surgical Abortion Surgical abortion can be performed, depending on preference and gestational age, under: • Local anaesthetic • Local anaesthetic plus sedation • General anaesthetic Prior to surgical abortion, medications are used for cervical priming. This involves softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators. Osmotic dilators are devices inserted into the cervix, that gradually expand as they absorb fluid, opening the cervical canal. There are two options for surgical abortion: ○ Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks) ○ Cervical dilatation and evacuation using forceps (between 14 and 24 weeks) Rhesus negative women having a surgical TOP should have anti-D prophylaxis. The NICE guidelines (2019) say it should be considered in women less than 10 weeks gestation.

Question 86

Post abortion after care

Answer 86

Post-Abortion Care Women may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure. A urine pregnancy test is performed 3 weeks after the abortion to confirm it is complete. Contraception is discussed and started where appropriate. Support and counselling is offered.

Question 87

Complications of an abortion

Answer 87

Complications • Bleeding • Pain • Infection • Failure of the abortion (pregnancy continues) • Damage to the cervix, uterus or other structures

Question 88

Hyperemesis Gravidarum

Answer 88

Hyperemesis Gravidarum Hyperemesis gravidarum is the severe form of nausea and vomiting in pregnancy. The RCOG guideline (2016) criteria for diagnosing hyperemesis gravidarum are “protracted” NVP plus: • More than 5 % weight loss compared with before pregnancy • Dehydration • Electrolyte imbalance

Question 89

Management of Hyperemesis Gravidarum

Answer 89

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 Ranitidine or omeprazole can be used if acid reflux is a problem. The RCOG also suggest complementary therapies that may be considered by the woman: ○ Ginger ○ Acupressure on the wrist at the PC6 point (inner wrist) may improve symptoms

Question 90

When would cases of Hyperemesis Gravidarum be admitted to hospital

Answer 90

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 Moderate-severe cases may require ambulatory care (e.g. early pregnancy assessment unit) or admission for: □ 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 91

What is a molar pregnancy and what are the two types?

Answer 91

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. 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. 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 92

Diagnosis of a molar pregnancy

Answer 92

Diagnosis Molar pregnancy behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur. There are a few things that can indicate a molar pregnancy versus a normal pregnancy: • 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) 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 93

Management of a molar pregnancy

Answer 93

Management 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 94

3 stages of labour

Answer 94

Labour and delivery normally occur between 37 and 42 weeks gestation. There are three stages of labour: • First stage – from the onset of labour (true contractions) until 10cm cervical dilatation • Second stage – from 10cm cervical dilatation until delivery of the baby • Third stage – from delivery of the baby until delivery of the placenta

Question 95

First stage of labour

Answer 95

First Stage The first stage of labour is from the onset of labour (true contractions) until the cervix is fully dilated to 10cm. It involves cervical dilation (opening up) and effacement (getting thinner). The “show” refers to the mucus plug in the cervix, which prevents bacteria from entering the uterus during pregnancy, falling out and creating space for the baby to pass through. The first stage has three phases: • 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 96

Braxton-Hicks Contractions

Answer 96

Braxton-Hicks Contractions 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 97

What are the signs of labour?

Answer 97

The signs of labour are: • Show (mucus plug from the cervix) • Rupture of membranes • Regular, painful contractions • Dilating cervix on examination

Question 98

Latent and established signs of the first part of labour

Answer 98

NICE guidelines on intrapartum care (2017) refer to the latent first stage and established list stage. 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 99

Second stage - passive stage of labour

Answer 99

Time between being fully dilated and urge to push Complete cervical dilatation but no pushing Often seen in women with epidural anaesthesia Recommended to leave 1-2 hours before pushing to reduce rate of instrumental delivery

Question 100

Second stage - active stage of labour

Answer 100

Maternal pushing until baby is born Should take less than 2 hours for primips, 1 hour for multips Assess fetal heart rate every 5 mins, may need syntocin if contractions wane, hourly vaginal examination and record urination As head descends, perineum stretches – applied gentle pressure on the perineum controls delivery of the head, reducing perineal tearing and reducing cranial injury to fetus

Question 101

Third stage of labour

Answer 101

Third stage Delivery of the placenta Placenta separates from uterus and uterus contracts to 24 week size Marked by a rush of blood with lengthening of the cord Normally takes under 1 hour but accelerated to around 5 mins by use of syntometrine (syntocin plus ergometrine IM) given as anterior shoulder is born Decreases incidence of PPH but can precipitate MI in susceptible individuals – just give oxytocin instead Check placenta for completeness

Question 102

Premature labour

Answer 102

Prematurity Prematurity is defined as birth before 37 weeks gestation. The more premature the baby, the worse the outcomes. 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. The World Health Organisation classify prematurity as: • Under 28 weeks: extreme preterm • 28 – 32 weeks: very preterm • 32 – 37 weeks: moderate to late preterm

Question 103

Vaginal progesterone use for prophylaxis

Answer 103

Vaginal Progesterone 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.

Question 104

Prophylaxis of preterm labour using cervical cerclage

Answer 104

Cervical Cerclage 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. Cervical cerclage is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy). “Rescue” cervical cerclage may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery.

Question 105

Preterm prelabour rupture of membranes

Answer 105

Preterm Prelabour Rupture of Membranes Preterm prelabour rupture of membranes is where the amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and in a preterm pregnancy (under 37 weeks gestation).

Question 106

How is preterm prelabour rupture of membranes diagnosed?

Answer 106

Diagnosis Rupture of membranes can be diagnosed by speculum examination revealing pooling of amniotic fluid in the vagina. No tests are required. Where there is doubt about the diagnosis, tests can be performed: • Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes • Placental alpha-microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1

Question 107

Preterm prelabour rupture of the membranes management

Answer 107

Management Prophylactic antibiotics should be given to prevent the development of chorioamnionitis. The NICE guidelines (2019) recommend erythromycin 250mg four times daily for ten days, or until labour is established if within ten days. Induction of labour may be offered from 34 weeks to initiate the onset of labour.

Question 108

Preterm labour with intact membranes

Answer 108

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

Question 109

How is preterm labour managed?

Answer 109

Management 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 110

Tocolysis (medication used to stop uterine contractions)

Answer 110

Tocolysis 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. Tocolysis can be used between 24 and 33 + 6 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).

Question 111

Use of antenatal steroids in pre term labour

Answer 111

Antenatal Steroids 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. An example regime would be two doses of intramuscular betamethasone, 24 hours apart.

Question 112

Use of magnesium sulfate in preterm labour

Answer 112

Magnesium Sulfate 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. 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 113

Indications for induction of labour

Answer 113

Indications Induction of labour can be used where patients go over the due date. IOL is offered between 41 and 42 weeks gestation. Induction of labour is also offered in situations where it is beneficial to start labour early, such as: • Prelabour rupture of membranes • Fetal growth restriction • Pre-eclampsia • Obstetric cholestasis • Existing diabetes • Intrauterine fetal death • Breech • Macrosomia • Insufficient uterine contractions • Prolonged labour Contraindications to Induction • Abnormal fetal lie • Placenta praevia • Cord prolapse • Active genital herpes

Question 114

What scoring system is used to measure whether labour should be induced?

Answer 114

The Bishop score is a scoring system used to determine whether to induce labour. Five things are assessed and given a score based on different criteria (minimum score is 0 and maximum is 13): • Fetal station (scored 0 – 3) • Cervical position (scored 0 – 2) • Cervical dilatation (scored 0 – 3) • Cervical effacement (scored 0 – 3) • Cervical consistency (scored 0 – 2) A score of 8 or more predicts a successful induction of labour. A score below this suggests cervical ripening may be required to prepare the cervix.

Question 115

How is induction of labour monitored?

Answer 115

Monitoring There are two means for monitoring during the induction of labour. • 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 116

Further management if induction of labour doesn’t work within 24 hours

Answer 116

Ongoing Management 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 117

What is uterine hyperstimulation?

Answer 117

Uterine Hyperstimulation • 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 criteria for uterine hyperstimulation varies slightly between guidelines (always check local policies and involve experienced seniors). The two criteria often given are: • Individual uterine contractions lasting more than 2 minutes in duration • More than five uterine contractions every 10 minutes

Question 118

Complications of uterine hyper stimulation and how is it managed?

Answer 118

Uterine hyperstimulation can lead to: • Fetal compromise, with hypoxia and acidosis • Emergency caesarean section • Uterine rupture Management of uterine hyperstimulation involves: • Removing the vaginal prostaglandins, or stopping the oxytocin infusion • Tocolysis with terbutaline

Question 119

Complications of induction

Answer 119

Complications of Induction • Uterine hyper stimulation • Uterine rupture • Intrauterine infection • Prolapsed cord • Amniotic fluid embolism May lead to necessity of caesarean section

Question 120

Different options for induction of labour

Answer 120

Membrane sweep Vaginal prostaglandin E2 (dinoprostone) Artificial rupture of membranes with an oxytocin infusion Oral mifepristone (anti-progesterone) plus misoprostol are used to induce labour where intrauterine fetal death has occurred.

Question 121

What is a membrane sweep (induction of labour)

Answer 121

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 122

Vaginal prostaglandin use in induction of labour

Answer 122

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 123

Cervical ripening balloon use in induction of labour

Answer 123

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 124

Artificial rupture of membranes with an oxytocin infusion

Answer 124

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. Contraindications to oxytocin • Possible obstructed labour • Feto-pelvic disproportion • Severe cardiovascular disease

Question 125

What is used to induce labour after intrauterine death has occurred?

Answer 125

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

Question 126

What is cardiotocography?

Answer 126

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. CTG can help guide decision making and delivery. However, it should not be used in isolation for decision making, and it is essential to take into account the overall clinical picture.

Question 127

Indications for continuous CTG monitoring in labour

Answer 127

Indications for Continuous CTG Monitoring The indications for continuous CTG monitoring in labour include: ○ 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 128

What can CTG measure during in labour?

Answer 128

Key Features There are five key features to look for on a CTG: § 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 129

What can too many/ too little contractions tell you about a labour?

Answer 129

Contractions Contractions are used to gauge the activity of labour. • Too few contractions indicate labour is not progressing. • Too many contractions can mean uterine hyperstimulation, which can lead to fetal compromise. It is also important to interpret the fetal heart rate in the context of the uterine contractions.

Question 130

DR C BRaVADO pneumonic to assess a CTG reading

Answer 130

DR C BRaVADO DR C BRaVADO is a mnemonic often taught to assess the features of a CTG in a structured way. It involves assessing in order: w DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG) w C – Contractions w BRa – Baseline Rate w V – Variability w A – Accelerations w D – Decelerations w O – Overall impression (given an overall impression of the CTG and clinical picture) If you are asked to assess a CTG in your exams, use the DR C BRaVADO structure to describe each feature in turn. Give an overall impression of the CTG as being normal (all features are reassuring), suspicious, pathological, or need for urgent intervention, as described in the NICE guidelines (2017).

Question 131

Use of oxytocin in labour

Answer 131

Oxytocin Oxytocin is a hormone secreted by the posterior pituitary gland. It is produced in the hypothalamus, but travels to the pituitary before being released into the general circulation. It has several effects on mood and social interactions in everyday life, but also plays a vital role in labour and delivery. 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. Infusions of oxytocin are used to: • Induce labour • Progress labour • Improve the frequency and strength of uterine contractions • 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 132

Ergometrine use in labour

Answer 132

Ergometrine Ergometrine is derived from ergot plants. It 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. Due to the action on the smooth muscle in blood vessels and gastrointestinal tract, it can cause several side effects, including hypertension, diarrhoea, vomiting and angina. It needs to be avoided in eclampsia, and used only with significant caution in patients with hypertension. Syntometrine is a combination drug containing oxytocin (Syntocinon) and ergometrine. It can be used for prevention or treatment of postpartum haemorrhage.

Question 133

Prostaglandin use in labour

Answer 133

Prostaglandins Prostaglandins act like local hormones, triggering specific effects in local tissues. Tissues throughout the entire body contain and respond to prostaglandins. They play a crucial role in menstruation and labour by stimulating contraction of the uterine muscles. They also have a role in ripening the cervix before delivery. One key prostaglandin to be aware of is dinoprostone, which is prostaglandin E2. This is used for induction of labour, and can come in one of three forms: • Vaginal pessaries (Propess) • Vaginal tablets (Prostin tablets) • Vaginal gel (Prostin gel) TOM TIP: Prostaglandins act as vasodilators, and lower blood pressure. NSAIDs such as ibuprofen and naproxen inhibit the action of prostaglandins. As a result, NSAIDs can increase blood pressure. NSAIDs are generally avoided in pregnancy, and also after delivery in women with raised blood pressure (although research has shed doubt on whether the effects on blood pressure is significant enough to justify avoiding them). NSAIDs (e.g. ibuprofen and mefenamic acid) are useful in treating dysmenorrhoea (painful periods), as they reduce the painful cramping of the uterus during menstruation.

Question 134

Why are NSAIDs avoided in pregnancy?

Answer 134

Prostaglandins act as vasodilators, and lower blood pressure. NSAIDs such as ibuprofen and naproxen inhibit the action of prostaglandins. As a result, NSAIDs can increase blood pressure. NSAIDs are generally avoided in pregnancy, and also after delivery in women with raised blood pressure (although research has shed doubt on whether the effects on blood pressure is significant enough to justify avoiding them). NSAIDs (e.g. ibuprofen and mefenamic acid) are useful in treating dysmenorrhoea (painful periods), as they reduce the painful cramping of the uterus during menstruation.

Question 135

Misoprostol

Answer 135

Misoprostol 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 136

Mifepristone

Answer 136

Mifepristone 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 137

Nifedipine use in pregnancy

Answer 137

Nifedipine 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 138

Terabutaline

Answer 138

Terbutaline Terbutaline is a beta-2 agonist, similar to salbutamol. It stimulates beta-2 adrenergic receptors. It acts on the smooth muscle of the uterus to suppress uterine contractions. It is used for tocolysis in uterine hyperstimulation, notably when the uterine contractions become excessive during induction of labour.

Question 139

Carboprost

Answer 139

Carboprost Carboprost is a synthetic prostaglandin analogue, meaning it binds to prostaglandin receptors. It stimulates uterine contraction. It is given as a deep intramuscular injection in postpartum haemorrhage, where ergometrine and oxytocin have been inadequate. Notably, it needs to be avoided or used with particular caution in patients with asthma, as it can cause a potentially life-threatening exacerbation of the asthma.

Question 140

Tranexamic Acid

Answer 140

Tranexamic Acid Tranexamic acid is an antifibrinolytic medication that reduces bleeding. It binds to plasminogen and prevents it from converting to plasmin. Plasmin is an enzyme that works to dissolve the fibrin within blood clots. Fibrin is a protein that helps hold blood clots together. Therefore, by decreasing the activity of the enzyme plasmin, tranexamic acid helps prevent the breakdown of blood clots. Tranexamic acid is used in the prevention and treatment of postpartum haemorrhage.

Question 141

Causes of preterm labour

Answer 141

• Uterine factors – increased pressure from the uterus due to multiple pregnancies, polydhramnios or increased intrabdominal pressure. (Stretch effect) • Cervical factors – Cervical incompetence due to LLETZ due to CIN/Cervical Ca. • Infection – Chorioamnionitis, Bacterial Vaginosis and Group B Strep. Can all cause preterm labour & Prelabour preterm rupture of membranes • Foetal factors – ‘Foetal survival response’ – if the foetus is distressed or hypoxic it can promote preterm labour as a ‘means of escape’

Question 142

What is progress in labour influenced by? (3P’s)

Answer 142

Progress in labour is influenced by the three P’s: • Power (uterine contractions) • Passenger (size, presentation and position of the baby) • Passage (the shape and size of the pelvis and soft tissues) Psyche can be added as a fourth P, referring to the support and antenatal preparation for labour and delivery.

Question 143

Three phases of the first stage of labour

Answer 143

First Stage of Labour The first stage has three phases: • 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. Delay in the first stage of labour is considered when there is either: • Less than 2cm of cervical dilatation in 4 hours • Slowing of progress in a multiparous women

Question 144

Second stage of labour

Answer 144

Second Stage 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. Delay in the second stage is when the active second stage (pushing) lasts over: • 2 hours in a nulliparous woman • 1 hour in a multiparous woman

Question 145

Management of failure to progress during labour

Answer 145

The main options for managing failure to progress are: • Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes • Oxytocin infusion • Instrumental delivery • Caesarean section

Question 146

Simple analgesia used in pregnancy

Answer 146

Simple Analgesia Paracetamol is frequently used in early labour. Codeine may be added for additional effect. NSAIDs are avoided.

Question 147

Entonox use in labour

Answer 147

Gas and Air (Entonox) Gas and air contains a mixture of 50% nitrous oxide and 50% oxygen. This is used during contractions for short term pain relief. The woman takes deep breaths using a mouthpiece at the start of a contraction, then stops using it as the contraction eases. It can cause lightheadedness, nausea or sleepiness.

Question 148

Intramuscular Pethidine or Diamorphine

Answer 148

Intramuscular Pethidine or Diamorphine Pethidine and diamorphine are opioid medications, usually given by intramuscular injection. They may help with anxiety and distress. They may cause drowsiness or nausea in the mother, and can cause respiratory depression in the neonate if given too close to birth. The effect on the baby may make the first feed more difficult.

Question 149

Patient controlled analgesia in labour

Answer 149

Patient Controlled Analgesia Patients may be offered the option of patient-controlled intravenous remifentanil. This involves the patient pressing a button at the start of a contraction to administer a bolus of this short-acting opiate medication. Patient-controlled analgesia requires careful monitoring. There needs to be input from an anaesthetist, and facilities in place if adverse events occur. This includes access to naloxone for respiratory depression, and atropine for bradycardia.

Question 150

Epidural use in labour

Answer 150

Epidural An epidural involves inserting a small tube (catheter) into the epidural space in the lower back. This is outside the dura mater, separate from the spinal cord and CSF. Local anaesthetic medications are infused through the catheter into the epidural space, where they diffuse to the surrounding tissues and through to the spinal cord, where they have an analgesic effect. This offers good pain relief during labour. Anaesthetic options are levobupivacaine or bupivacaine, usually mixed with fentanyl. Adverse effects: • Headache after insertion • Hypotension • Motor weakness in the legs • Nerve damage • Prolonged second stage • Increased probability of instrumental delivery 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 151

Umbilical cord prolapse

Answer 151

• 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. • 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). • Being in an abnormal lie provides space for the cord to prolapse below the presenting part. • In a cephalic lie, the head typically descends into the pelvis, without room for the cord to descend.

Question 152

How is umbilical cord prolapse diagnosed?

Answer 152

Diagnosis • Umbilical cord prolapse should be 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.

Question 153

Management of umbilical cord prolapse

Answer 153

Management • 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. • Pushing the cord back in is not recommended. • The cord should be kept warm and wet and have minimal handling whilst waiting for delivery (handling causes vasospasm). • When the baby is compressing a prolapsed cord, the presenting part can be pushed upwards to prevent it compressing the cord. • 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. • Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by caesarean section.

Question 154

What is shoulder dystocia?

Answer 154

• 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. • This requires additional obstetric manoeuvres to enable delivery of the rest of the body. Shoulder dystocia is an obstetric emergency. • Shoulder dystocia is often caused by macrosomia secondary to gestational diabetes.

Question 155

Management of shoulder dystocia

Answer 155

Management 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. It is not always necessary. 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 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. 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 156

The key complications of shoulder dystocia

Answer 156

Complications The key complications of shoulder dystocia are: • Fetal hypoxia (and subsequent cerebral palsy) • Brachial plexus injury and Erb’s palsy • Perineal tears • Postpartum haemorrhage

Question 157

Instrumental delivery

Answer 157

Instrumental delivery refers to a vagina delivery assisted by either a ventouse suction cup or forceps. Tools are used to help deliver the baby’s head. About 10% of births in the UK are assisted by an instrumental delivery. The procedure can usually be carried out on the labour ward. However, if there are concerns about whether it will be successful, the woman may be moved to theatre so that rapid delivery by caesarean section can be performed if necessary. A single dose of co-amoxiclav is recommended after instrumental delivery to reduce the risk of maternal infection.

Question 158

Indications for instrumental delivery

Answer 158

Indications The decision to perform an instrumental delivery is based on the clinical judgement of the midwife or obstetrician. Some key indications are: Failure to progress Fetal distress Maternal exhaustion Control of the head in various fetal positions TOM TIP: It is worth remembering there is an increased risk of requiring an instrumental delivery when an epidural is in place for analgesia.

Question 159

Risks of an instrumental delivery

Answer 159

Having an instrumental delivery increases the risk to the mother of: Postpartum haemorrhage Episiotomy Perineal tears Injury to the anal sphincter Incontinence of the bladder or bowel Nerve injury (obturator or femoral nerve) The key risks to remember to the baby are: Cephalohaematoma with ventouse Facial nerve palsy with forceps Rarely there can be serious risks to the baby: Subgaleal haemorrhage (most dangerous) Intracranial haemorrhage Skull fracture Spinal cord injury

Question 160

Ventouse

Answer 160

Ventouse A ventouse is essentially a suction cup on a cord. The suction cup goes on the baby’s head, and the doctor or midwife applies careful traction to the cord to help pull the baby out of the vagina. The main complication for the baby is cephalohaematoma. This involves a collection of blood between the skull and the periosteum.

Question 161

Forcep use in delivery

Answer 161

Forceps look like large metal salad tongs. They come as two pieces of curved metal that attach together, go either side of the baby’s head and grip the head in a way that allows the doctor or midwife to apply careful traction and pull the head from the vagina. The main complication for the baby is facial nerve palsy, with facial paralysis on one side. Forceps delivery can leave bruises on the baby’s face. Rarely the baby can develop fat necrosis, leading to hardened lumps of fat on their cheeks. Fat necrosis resolves spontaneously over time.

Question 162

Nerve injuries related to an instrumental delivery

Answer 162

Rarely an instrumental delivery may result in nerve injury for the mother. This usually resolves over 6 – 8 weeks. The affected nerves may be: Femoral nerve Obturator nerve The femoral nerve may be compressed against the inguinal canal during a forceps delivery. Injury to this nerve causes weakness of knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg. The obturator nerve may be compressed by forceps during instrumental delivery or by the fetal head during normal delivery. Injury causes weakness of hip adduction and rotation, and numbness of the medial thigh.

Question 163

Nerve injuries during delivery (not related to instrument delivery)

Answer 163

Three other nerve injuries can occur during birth that are usually unrelated to instrumental delivery: Lateral cutaneous nerve of the thigh Lumbosacral plexus Common peroneal nerve The lateral cutaneous nerve of the thigh runs under the inguinal ligament. Prolonged flexion at the hip while in the lithotomy position can result in injury, causing numbness of the anterolateral thigh. The lumbosacral plexus may be compressed by the fetal head during the second stage of labour. Injury to this network of nerves nerve can cause foot drop and numbness of the anterolateral thigh, lower leg and foot. The common peroneal nerve may be compressed on the head of the fibula whilst in the lithotomy position. Injury to this nerve causes foot drop and numbness in the lateral lower leg.

Question 164

When are perineal tears more likely

Answer 164

Perineal tears are more common with: • First births (nulliparity) • Large babies (over 4kg) • Shoulder dystocia • Asian ethnicity • Occipito-posterior position • Instrumental deliveries

Question 165

Classification of perineal tears

Answer 165

Classification There are four degrees of perineal tear, each involving injury to tissue beyond the previous: • First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin • Second-degree – including the perineal muscles, but not affecting the anal sphincter • Third-degree – including the anal sphincter, but not affecting the rectal mucosa • Fourth-degree – including the rectal mucosa Third-degree tears can be subcategorised as: ○ 3A – less than 50% of the external anal sphincter affected ○ 3B – more than 50% of the external anal sphincter affected ○ 3C – external and internal anal sphincter affected

Question 166

Management of perineal tears

Answer 166

Management First-degree tears usually do not require any sutures. When a perineal tear larger than first degree occurs, the mother usually requires sutures to correct the injury. A third or fourth-degree tear is likely to need repairing in theatre. Additional measures are taken to reduce the risk of complications: • Broad-spectrum antibiotics to reduce the risk of infection • Laxatives to reduce the risk of constipation and wound dehiscence • Physiotherapy to reduce the risk and severity of incontinence • Followup to monitor for longstanding complications Women that are symptomatic after third or fourth-degree tears are offered an elective caesarean section in subsequent pregnancies.

Question 167

Complications of perineal tears

Answer 167

Complications Short term complications after repair include: • Pain • Infection • Bleeding • Wound dehiscence or wound breakdown Perineal tears can lead to several lasting complications: ○ 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 168

What is an episiotomy?

Answer 168

Episiotomy An episiotomy is where the obstetrician or midwife cuts the perineum before the baby is delivered. This is done in anticipation of needing additional room for delivery of the baby (e.g. before forceps delivery). It is performed under local anaesthetic. A cut is made at around 45 degrees diagonally, from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter. This is called a mediolateral episiotomy. The cut is sutured after delivery.

Question 169

Small for gestational age

Answer 169

Small for gestational age is defined as a fetus that measures below the 10th centile for their gestational age. Two measurements on ultrasound are used to assess the fetal size: • Estimated fetal weight (EFW) • Fetal abdominal circumference (AC)

Question 170

What is fetal growth restriction?

Answer 170

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. The causes of fetal growth restriction can be divided into two categories: § Placenta mediated growth restriction § Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality

Question 171

Placenta mediated growth restriction

Answer 171

Placenta mediated growth restriction refers to conditions that affect the transfer of nutrients across the placenta: § Idiopathic § Pre-eclampsia § Maternal smoking § Maternal alcohol § Anaemia § Malnutrition § Infection § Maternal health conditions

Question 172

Non placenta medicated growth restrictions

Answer 172

Non-placenta medicated growth restriction refers to pathology of the fetus, such as: § Genetic abnormalities § Structural abnormalities § Fetal infection § Errors of metabolism

Question 173

How big is large for gestational age?

Answer 173

• Babies are defined as being large for gestational age (also known as macrosomia) when the weight of the newborn is more than 4.5kg at birth. • During pregnancy, an estimated fetal weight above the 90th centile is considered large for gestational age.

Question 174

Causes of macrosomia

Answer 174

Causes of Macrosomia • Constitutional • Maternal diabetes • Previous macrosomia • Maternal obesity or rapid weight gain • Overdue • Male baby

Question 175

Risks to the mother when delivering a macrosomia baby

Answer 175

Risks The risks to the mother include: ○ Shoulder dystocia ○ Failure to progress ○ Perineal tears ○ Instrumental delivery or caesarean ○ Postpartum haemorrhage ○ Uterine rupture (rare)

Question 176

Risks to the baby when macrosomia

Answer 176

The risks to the baby include: ○ Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia) ○ Neonatal hypoglycaemia ○ Obesity in childhood and later life ○ Type 2 diabetes in adulthood

Question 177

Management for large for gestational age baby

Answer 177

Management Investigations for a large for gestational age baby are: □ Ultrasound to exclude polyhydramnios and estimate the fetal weight □ Oral glucose tolerance test for gestational diabetes

Question 178

Twins and multiple pregnancies key definitions: • Monozygotic • Dizygotic • Monoamniotic • Diamniotic • Monochorionic • Dichorionic

Answer 178

Types There are some key definitions to become familiar with relating to twin and multiple pregnancy: • Monozygotic: identical twins (from a single zygote) • Dizygotic: non-identical (from two different zygotes) • Monoamniotic: single amniotic sac • Diamniotic: two separate amniotic sacs • Monochorionic: share a single placenta • Dichorionic: two separate placentas The best outcomes are with diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.

Question 179

Complications to the mother with having twins

Answer 179

Risks to the mother: □ Anaemia □ Polyhydramnios □ Hypertension □ Malpresentation □ Spontaneous preterm birth □ Instrumental delivery or caesarean □ Postpartum haemorrhage

Question 180

Risks to the fetuses and neonates with twins

Answer 180

Risks to the fetuses and neonates: ® Miscarriage ® Stillbirth ® Fetal growth restriction ® Prematurity ® Twin-twin transfusion syndrome ® Twin anaemia polycythaemia sequence ® Congenital abnormalities

Question 181

Twin - Twin Transfusion Syndrome

Answer 181

Twin-Twin Transfusion Syndrome • Twin-twin transfusion syndrome occurs when the 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. • The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. • The donor has growth restriction, anaemia and oligohydramnios. • There will be a discrepancy between the size of the fetuses. • Women with twin-twin transfusion syndrome need to be referred to a tertiary specialist fetal medicine centre. • In severe cases, laser treatment may be used to destroy the connection between the two blood supplies.

Question 182

Delivery of twins

Answer 182

Delivery Monoamniotic twins require elective caesarean section at between 32 and 33 + 6 weeks. Diamniotic twins (aim to deliver between 37 and 37 + 6 weeks): ○ 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 ○ Elective caesarean is advised when the presenting twin is not cephalic presentation

Question 183

Asymptomatic bacteriurea in pregnancy

Answer 183

Asymptomatic Bacteriuria • Asymptomatic bacteriuria refers to bacteria present in the urine, without symptoms of infection. • Pregnant women with asymptomatic bacteriuria are at higher risk of developing lower urinary tract infections and pyelonephritis, and subsequently at risk of preterm birth. • Pregnant women are tested for asymptomatic bacteriuria at booking and routinely throughout pregnancy. ○ This involves sending a urine sample to the lab for microscopy, culture and sensitivities (MC&S). • Testing for bacteria in the urine of asymptomatic patients is not recommended as it may lead to unnecessary antibiotics. ○ Pregnant women are an exception to this rule, due to the adverse outcomes associated with infection.

Question 184

Urine dipstick showing a UTI

Answer 184

Urine Dipstick Nitrites are produced by gram-negative bacteria (such as E. coli). • These bacteria break down nitrates, a normal waste product in urine, into nitrites. • The nitrites in the urine suggest the presence of bacteria. Leukocytes refer to white blood cells. • There are normally a small number of leukocytes in the urine, but a significant rise can be the result of an infection, or alternative cause of inflammation. • Urine dipstick tests examine for leukocyte esterase, a product of leukocytes, which gives an indication to the number of leukocytes in the urine. Nitrites are a more accurate indication of infection than leukocytes. During pregnancy, midstream urine (MSU) samples are routinely sent to the microbiology lab to be cultured and to have sensitivity testing.

Question 185

Management of a UTI in pregnancy

Answer 185

Management Urinary tract infection in pregnancy requires 7 days of antibiotics. The antibiotic options are: □ Nitrofurantoin (avoid in the third trimester) □ Amoxicillin (only after sensitivities are known) □ Cefalexin Nitrofurantoin needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells). Trimethoprim needs to be avoided in the first trimester as it is works as a folate antagonist. □ Folate is important in early pregnancy for the normal development of the fetus. □ Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (i.e. spina bifida). □ It is not known to be harmful later in pregnancy, but is generally avoided unless necessary.

Question 186

When are women screened for anaemia during pregnancy and why does it occur?

Answer 186

Women are routinely screened for anaemia twice during pregnancy: • Booking clinic • 28 weeks gestation • During pregnancy, the plasma volume increases. ○ This results in a reduction in the haemoglobin concentration. ○ The blood is diluted due to the higher plasma volume. • It is important to optimise the treatment of anaemia during pregnancy so that the woman has reasonable reserves, in case there is significant blood loss during delivery.

Question 187

Presentation of anaemia in pregnancy

Answer 187

Presentation Often anaemia in pregnancy is asymptomatic. Women may have: ○ Shortness of breath ○ Fatigue ○ Dizziness ○ Pallor

Question 188

Management of anaemia in pregnancy: Iron, B12, Folate, Thalassaemia and SCD

Answer 188

Management Iron 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 The increased plasma volume and B12 requirements often result in a low B12 in pregnancy. Women with low B12 should be tested for pernicious anaemia (checking for intrinsic factor antibodies). Advice should be sought from a haematologist regarding further investigations and treatment of low B12 in pregnancy. Treatment options for low B12 are: ○ Intramuscular hydroxocobalamin injections ○ Oral cyanocobalamin tablets Folate All women should already be taking folic acid 400mcg per day. Women with folate deficiency are started on folic acid 5mg daily. Thalassaemia and Sickle Cell Anaemia Women with a haemoglobinopathy will be managed jointly with a specialist haematologist. They require high dose folic acid (5mg), close monitoring and transfusions when required.

Question 189

Risk factors for VTE in pregnancy

Answer 189

• Smoking • Parity ≥ 3 • Age > 35 years • BMI > 30 • Reduced mobility • Multiple pregnancy • Pre-eclampsia • Gross varicose veins • Immobility • Family history of VTE • Thrombophilia • IVF pregnancy

Question 190

When should prophylaxis be started for VTE in pregnancy?

Answer 190

The RCOG guidelines (2015) advise starting prophylaxis from: • 28 weeks if there are three risk factors • First trimester if there are four or more of these risk factors There are additional scenarios where prophylaxis is considered, even in the absence of other risk factors: • Hospital admission • Surgical procedures • Previous VTE • Medical conditions such as cancer or arthritis • High-risk thrombophilias • Ovarian hyperstimulation syndrome

Question 191

What prophylaxis is used in women at risk of VTE in pregnancy?

Answer 191

□ Women at increased risk of VTE should receive prophylaxis with low molecular weight heparin (LMWH) unless contraindicated. ○ Examples of LMWH are 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: □ Intermittent pneumatic compression with equipment that inflates and deflates to massage the legs □ Anti-embolic compression stockings

Question 192

Are the Wells score and D dimer used to screen for DVT in pregnancy?

Answer 192

TOM TIP: 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 193

Management of a DVT/PE in pregnancy

Answer 193

Management Management of venous thromboembolism in pregnancy is with low molecular weight heparin (LMWH). Examples of LMWH are enoxaparin, dalteparin and tinzaparin. The dose is based on the woman’s weight at the booking clinic, or from early pregnancy. 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. An individual risk assessment is performed before stopping anticoagulation, with advice from a haematologist if necessary. Women with a massive PE and haemodynamic compromise need immediate management by an experienced team of medical doctors, obstetricians, radiologists and others. This is a life-threatening scenario. Treatment options are: Unfractionated heparin Thrombolysis Surgical embolectomy

Question 194

What is pre eclampsia?

Answer 194

Pre-eclampsia refers to new high blood pressure in pregnancy with end-organ dysfunction, notably with proteinuria. • It occurs after 20 weeks gestation, when the spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels. Pre-eclampsia is a significant cause of maternal and fetal morbidity and mortality. Without treatment, it can lead to: • Maternal organ damage • Fetal growth restriction • Seizures • Early labour • Death.

Question 195

Pre eclampsia triad features

Answer 195

• Hypertension • Proteinuria • Oedema

Question 196

Definitions: Chronic hypertension Pregnancy induced hypertension Pre eclampsia Eclampsia

Answer 196

Definitions Chronic hypertension is high blood pressure that exists before 20 weeks gestation and is longstanding. • This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia. Pregnancy-induced hypertension or gestational hypertension is hypertension occurring after 20 weeks gestation, without proteinuria. Pre-eclampsia is pregnancy-induced hypertension associated with organ damage, notably proteinuria. Eclampsia is when seizures occur as a result of pre-eclampsia.

Question 197

Pathophysiology of pre eclampsia

Answer 197

Pathophysiology • 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, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.

Question 198

Risk factors to pre eclampsia in pregnancy

Answer 198

The NICE guidelines categorise the risk factors into high-risk and moderate-risk factors. High-risk factors are: ○ Pre-existing hypertension ○ Previous hypertension in pregnancy ○ Existing autoimmune conditions (e.g. systemic lupus erythematosus) ○ Diabetes ○ Chronic kidney disease Moderate-risk factors are: ○ Older than 40 ○ BMI > 35 ○ More than 10 years since previous pregnancy ○ Multiple pregnancy ○ First pregnancy ○ Family history of pre-eclampsia These risk factors are used to determine which women are offered aspirin as prophylaxis against pre-eclampsia. ○ Women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors.

Question 199

Prophylaxis of pre eclampsia

Answer 199

○ Women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors.

Question 200

How is pre eclampsia diagnosed?

Answer 200

Diagnosis The NICE guidelines (2019) advise a diagnosis can be made with a: Systolic blood pressure above 140 mmHg Diastolic blood pressure above 90 mmHg PLUS any of: Proteinuria (1+ or more on urine dipstick) Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies) Proteinuria can be quantified using: Urine protein:creatinine ratio (above 30mg/mmol is significant) Urine albumin:creatinine ratio (above 8mg/mmol is significant) The NICE guidelines (2019) recommend the use of placental growth factor (PlGF) testing on one occasion during pregnancy in women suspected of having pre-eclampsia. Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low. NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.

Question 201

How is gestational hypertension managed?

Answer 201

When gestational hypertension (without proteinuria) is identified, the general management involves: – Treating to aim for a blood pressure below 135/85 mmHg – Admission for women with a blood pressure above 160/110 mmHg – Urine dipstick testing at least weekly – Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile) – Monitoring fetal growth by serial growth scans – PlGF testing on one occasion

Question 202

Medical management of pre eclampsia

Answer 202

Medical management of pre-eclampsia is with: • Labetolol is first-line as an antihypertensive • Nifedipine (modified-release) is commonly used second-line • Methyldopa is used third-line (needs to be stopped within two days of birth) • Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia • IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures • Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Question 203

Management of eclampsia

Answer 203

Eclampsia Eclampsia refers to the seizures associated with pre-eclampsia. IV magnesium sulphate is used to manage seizures associated with pre-eclampsia.

Question 204

HELLP Syndrome

Answer 204

HELLP Syndrome 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: w Haemolysis w Elevated Liver enzymes w Low Platelets

Question 205

Gestational diabetes What causes it Complications

Answer 205

Gestational diabetes refers to diabetes triggered by 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. • This has implications for birth, mainly posing a risk of shoulder dystocia. Longer-term, 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 206

Risk factors for gestational diabetes

Answer 206

Risk Factors The NICE guidelines (2015) list the risk factors that warrant testing for gestational diabetes: • 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)

Question 207

What features suggest gestational diabetes?

Answer 207

○ Large for dates fetus ○ Polyhydramnios (increased amniotic fluid) ○ Glucose on urine dipstick

Question 208

How is gestational diabetes diagnosed?

Answer 208

Oral glucose tolerance test An OGTT should be performed in the morning after a fast (they can drink plain water). The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours. Normal results are: • Fasting: < 5.6 mmol/l • At 2 hours: < 7.8 mmol/l Results higher than these values are used to diagnose gestational diabetes. TOM TIP: It is really easy to remember the cutoff for gestational diabetes as simply 5 – 6 – 7 – 8.

Question 209

When would an OGTT be done throughout pregnancy?

Answer 209

The screening test of choice for gestational diabetes is an oral glucose tolerance test (OGTT). An OGTT is used in patients with risk factors for gestational diabetes, and also when there are features that suggest gestational diabetes: ○ Large for dates fetus ○ Polyhydramnios (increased amniotic fluid) ○ Glucose on urine dipstick

Question 210

How should pregnant women manage their type 2 diabetes?

Answer 210

Women with type 2 diabetes are managed using metformin and insulin, and other oral diabetic medications should be stopped.

Question 211

Post natal care for gestational diabetes

Answer 211

Diabetes improves immediately after birth. Women with gestational diabetes can stop their diabetic medications immediately after birth. ◊ They need follow up to test their fasting glucose after at least six weeks.

Question 212

Post natal care for diabetic women

Answer 212

Women with existing diabetes should lower their insulin doses and be wary of hypoglycaemia in the postnatal period. ◊ The insulin sensitivity will increase after birth and with breastfeeding. Babies of mothers with diabetes are at risk of: ◊ Neonatal hypoglycaemia ◊ Polycythaemia (raised haemoglobin) ◊ Jaundice (raised bilirubin) ◊ Congenital heart disease ◊ Cardiomyopathy

Question 213

Neonatal hypoglycaemia

Answer 213

Babies need close monitoring for neonatal hypoglycaemia, with regular blood glucose checks and frequent feeds. ◊ The aim is to maintain their blood sugar above 2 mmol/l, and if it falls below this, they may need IV dextrose of nasogastric feeding.

Question 214

Complications of gestational diabetes on the baby

Answer 214

Macrosomia and neonatal hypoglycaemia. Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone

Question 215

Obstetrics cholestasis

Answer 215

Obstetric cholestasis is also known as intrahepatic cholestasis of pregnancy. Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver. The condition resolves after delivery of the baby. Obstetric cholestasis is a relatively common complication of pregnancy, occurring in around 1% of pregnant women. It usually develops later in pregnancy (i.e. after 28 weeks), and is thought to be the result of increased oestrogen and progesterone levels. • There seems to be a genetic component. • It is more common in women of South Asian ethnicity. Bile acids are produced in the liver from the breakdown of cholesterol. Bile acids flow from liver to the hepatic ducts, past the gallbladder and out of the bile duct to the intestines. In obstetric cholestasis, the outflow of bile acids is reduced, causing them to build up in the blood, resulting in the classic symptoms of itching (pruritis). Obstetric cholestasis is associated with an increased risk of stillbirth.

Question 216

Symptoms of obstetric cholestasis

Answer 216

Presentation Obstetric cholestasis typically present later in pregnancy, particularly in the third trimester. Itching (pruritis) is the main symptom, particularly affecting the palms of the hands and soles of the feet. Other symptoms are related to cholestasis and outflow obstruction in the bile ducts: • Fatigue • Dark urine • Pale, greasy stools • Jaundice Importantly, there is no rash associated with obstetric cholestasis. • If a rash is present, an alternative diagnosis should be considered, such as polymorphic eruption of pregnancy or pemphigoid gestationis.

Question 217

Other causes of pruritus and deranged LFTs in pregnancy other than obstetric cholestasis

Answer 217

Differential Diagnosis Other causes of pruritus and deranged LFTs should be excluded, for example: ○ Gallstones ○ Acute fatty liver ○ Autoimmune hepatitis ○ Viral hepatitis

Question 218

How is obstetric cholestasis diagnosed?

Answer 218

Investigations Women presenting with pruritus should have liver function tests and bile acids checked. Obstetric cholestasis will cause: § Abnormal liver function tests (LFTs), mainly ALT, AST and GGT § Raised bile acids TOM TIP: It is normal for alkaline phosphatase (ALP) to increase in pregnancy. This is because the placenta produces ALP. A rise in ALP without other abnormal LFT results is usually due to placental production of ALP, rather than liver pathology.

Question 219

Management of obstetric cholestasis

Answer 219

Ursodeoxycholic acid is the primary treatment for obstetric cholestasis. It improves LFTs, bile acids and symptoms. Symptoms of itching can be managed with: □ Emollients (i.e. calamine lotion) to soothe the skin □ Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching) Usually treated by symptom management primari

Question 220

Acute fatty liver of pregnancy

Answer 220

• Acute fatty liver of pregnancy is a rare condition that occurs in the third trimester of pregnancy. • There is a rapid accumulation of fat within the liver cells (hepatocytes), causing acute hepatitis. • There is a high risk of liver failure and mortality, for both the mother and fetus.

Question 221

Pathophysiology of acute fatty liver of pregnancy

Answer 221

Pathophysiology • Acute fatty liver of pregnancy results from impaired processing of fatty acids in the placenta. • This is the result of a genetic condition in the fetus that impairs fatty acid metabolism. • The most common cause is long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus, which is an autosomal recessive condition. • This mode of inheritance means the mother will also have one defective copy of the gene. • The LCHAD enzyme is important in fatty acid oxidation, breaking down fatty acids to be used as fuel. • The fetus and placenta are unable to break down fatty acids. • These fatty acids enter the maternal circulation, and accumulate in the liver. • The mother’s defective copy of the gene may also contribute to the accumulation of fatty acids. • The accumulation of fatty acids in the mother’s liver leads to inflammation and liver failure.

Question 222

Presentation of acute fatty liver of pregnancy

Answer 222

Presentation The presentation is with vague symptoms associated with hepatitis : • General malaise and fatigue • Nausea and vomiting • Jaundice • Abdominal pain • Anorexia (lack of appetite) • Ascites

Question 223

What would bloods of acute fatty liver of pregnancy show?

Answer 223

Bloods Liver function tests will show elevated liver enzymes (ALT and AST). Other bloods may be deranged, with: ○ Raised bilirubin ○ Raised WBC count ○ Deranged clotting (raised prothrombin time and INR) ○ Low platelets TOM TIP: In your exams, elevated liver enzymes and low platelets should make you think of HELLP syndrome rather than acute fatty liver of pregnancy. HELLP syndrome is much more common, but keep acute fatty liver of pregnancy in mind as a differential.

Question 224

Acute fatty liver of pregnancy management

Answer 224

Management Acute fatty liver of pregnancy is an obstetric emergency and requires prompt admission and delivery of the baby. Most patients will recover after delivery. Management also involves treatment of acute liver failure if it occurs, including consideration of liver transplant.

Question 225

Placenta Pravia and the different grades

Answer 225

Placenta praevia is where the placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus. The RCOG guidelines (2018) recommend the following definitions: • Low-lying placenta is used when the placenta is within 20mm of the internal cervical os • Placenta praevia is used only when the placenta is over the internal cervical os Placenta praevia occurs in around 1% of pregnancies. • It is a notable cause of antepartum haemorrhage. 1. Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os 2. Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os 3. Partial praevia, or grade III – the placenta is partially covering the internal cervical os 4. Complete praevia, or grade IV – the placenta is completely covering the internal cervical os

Question 226

Name three causes of antepartum haemorrhage

Answer 226

1. Placenta praevia 2. Placental abruption 3. Vasa praevia. These are serious causes with high morbidity and mortality.

Question 227

Causes of spotting or minor bleeding in pregnancy

Answer 227

Causes of spotting or minor bleeding in pregnancy include • Cervical ectropion • Infection • Vaginal abrasions from intercourse or procedures.

Question 228

What can placental praevia lead too?

Answer 228

Risks Placenta praevia is associated with increased morbidity and mortality for the mother and fetus. The risks include: ○ Antepartum haemorrhage ○ Emergency caesarean section ○ Emergency hysterectomy ○ Maternal anaemia and transfusions ○ Preterm birth and low birth weight ○ Stillbirth

Question 229

Risk factors for placental praevia

Answer 229

Risk Factors The risk factors for placenta praevia are: □ Previous caesarean sections □ Previous placenta praevia □ Older maternal age □ Maternal smoking □ Structural uterine abnormalities (e.g. fibroids) □ Assisted reproduction (e.g. IVF)

Question 230

Presentation and diagnosis of placenta praevia

Answer 230

Presentation and Diagnosis • The 20-week anomaly scan is used to assess the position of the placenta and diagnose placenta praevia. • Many women with placenta praevia are asymptomatic. • It may present with painless vaginal bleeding in pregnancy (antepartum haemorrhage). • Bleeding usually occurs later in pregnancy (around or after 36 weeks).

Question 231

Vasa praevia

Answer 231

• 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 232

Management of vasa praevia

Answer 232

Management For asymptomatic women with vasa praevia, the RCOG guidelines (2018) recommend: □ Corticosteroids, given from 32 weeks gestation to mature the fetal lungs □ 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. After stillbirth or unexplained fetal compromise during delivery, the placenta is examined for evidence of vasa praevia as a possible cause.

Question 233

Placental abruption

Answer 233

Placental abruption refers to when the placenta separates from the wall of the uterus during pregnancy. • The site of attachment can bleed extensively after the placenta separates. Placental abruption is a significant cause of antepartum haemorrhage.

Question 234

Risk factors for placental abruption

Answer 234

Risk Factors The risk factors for placental abruption are: • Previous placental abruption • Pre-eclampsia • Bleeding early in pregnancy • Trauma (consider domestic violence) • Multiple pregnancy • Fetal growth restriction • Multigravida • Increased maternal age • Smoking • Cocaine or amphetamine use

Question 235

Presentation of placental abruption

Answer 235

Presentation The typical presentation of placental abruption is with: ○ Sudden onset severe abdominal pain that is continuous ○ Vaginal bleeding (antepartum haemorrhage) ○ Shock (hypotension and tachycardia) ○ Abnormalities on the CTG indicating fetal distress ○ Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage

Question 236

Management of placental abruption

Answer 236

Management There are no reliable tests for diagnosing placental abruption. It is a clinical diagnosis based on the presentation. Placental abruption is an obstetric emergency. □ The urgency depends on the amount of placental separation, extent of bleeding, haemodynamic stability of the mother and condition of the fetus. □ It is important to consider concealed haemorrhage, where the vaginal bleeding may be disproportionate to the uterine bleeding. The initial steps with major or massive haemorrhage are: □ Urgent involvement of a senior obstetrician, midwife and anaesthetist □ 2 x grey cannula □ Bloods include FBC, UE, LFT and coagulation studies □ Crossmatch 4 units of blood □ Fluid and blood resuscitation as required □ CTG monitoring of the fetus □ Close monitoring of the mother

Question 237

Pathophysiology of placenta accreta

Answer 237

Pathophysiology There are three layers to the uterine wall: 1. Endometrium, the inner layer that contains connective tissue (stroma), epithelial cells and blood vessels 2. Myometrium, the middle layer that contains smooth muscle 3. Perimetrium, the outer layer, which is a serous membrane similar to the peritoneum (also known as serosa) Usually the placenta attaches to the endometrium. • This allows the placenta to separate cleanly during the third stage of labour, after delivery of the baby. With placenta accreta, the placenta embeds past the endometrium, into the myometrium and beyond. • This may happen due to a defect in the endometrium. • Imperfections may occur due to previous uterine surgery, such as a caesarean section or curettage procedure. • The deep implantation makes it very difficult for the placenta to separate during delivery, leading to extensive bleeding (postpartum haemorrhage).

Question 238

Risk factors for placental accreta

Answer 238

Risk Factors § 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 239

Presentation of placental accreta

Answer 239

Presentation Placenta accreta does not typically cause any symptoms during pregnancy. It can present with 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 240

Breech and types of breech

Answer 240

Breech presentation refers to when the presenting part of the fetus (the lowest part) is the legs and bottom. This is opposed to cephalic presentation, where the head is the presenting part. Breech presentation occurs in less than 5% of pregnancies by 37 weeks gestation. Types of Breech • 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, also known as frank breech, with both legs flexed at the hip and extended at the knee • Footling breech, with a foot is presenting through the cervix with the leg extended

Question 241

External Cephalic Version

Answer 241

External Cephalic Version ○ External cephalic version (ECV) is a technique used to attempt to turn a fetus from the breech position to a cephalic position using pressure on the pregnant abdomen. ○ It is about 50% successful. External cephalic version is used in babies that are breech: ○ After 36 weeks for nulliparous women (women that have not previously given birth) ○ After 37 weeks in women that have given birth previously Women are given tocolysis to relax the uterus before the procedure. ○ Tocolysis is with subcutaneous terbutaline. ○ Terbutaline is a beta-agonist similar to salbutamol. ○ It reduces the contractility of the myometrium, making it easier for the baby to turn.

Question 242

Causes of still birth

Answer 242

Causes Many of the conditions that can affect pregnancy increase the risk of stillbirth. Unexplained stillbirth is common. The causes of stillbirth include: • Unexplained (around 50%) • Pre-eclampsia • Placental abruption • Vasa praevia • Cord prolapse or wrapped around the fetal neck • Obstetric cholestasis • Diabetes • Thyroid disease • Infections, such as rubella, parvovirus and listeria • Genetic abnormalities or congenital malformations

Question 243

Factors that increase the risk of stillbirth

Answer 243

Factors that increase the risk of stillbirth include: • Fetal growth restriction • Smoking • Alcohol • Increased maternal age • Maternal obesity • Twins • Sleeping on the back (as opposed to either side)

Question 244

Preventative measures of still birth

Answer 244

Prevention A risk assessment for having a baby that is small for gestational age (SGA) or with fetal growth restriction (FGR) is performed on all pregnant women. § Having risk factors for SGA increases the risk of stillbirth. § Those at risk have the fetal growth closely monitored with serial growth scans. § This helps identify women that need further investigations and management. § They may need planned early delivery when the growth is static, or other concerns are identified. Women at risk of pre-eclampsia are given aspirin. Any modifiable risk factors for stillbirth are treated, for example, stopping smoking, avoiding alcohol and effective control of diabetes. Sleeping on the side (not the back) is advised. There are three key symptoms to always ask during pregnancy. Women would report these immediately if they occur: § Reduced fetal movements § Abdominal pain § Vaginal bleeding

Question 245

What can be used to suppress lactation after a stillbirth

Answer 245

Dopamine agonists (e.g. cabergoline) can be used to suppress lactation after stillbirth.

Question 246

What testing is carried out following a still birth?

Answer 246

With parental consent, testing is carried out after stillbirth to determine the cause: □ Genetic testing of the fetus and placenta □ Postmortem examination of the fetus (including xrays) □ Testing for maternal and fetal infection □ Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia Identifying the cause can help reduce the risk in future pregnancies.

Question 247

Causes of cardiac arrest in pregnancy

Answer 247

4 Ts: • Thrombosis (i.e. PE or MI) • Tension pneumothorax • Toxins • Tamponade (cardiac) 4 Hs: • Hypoxia • Hypovolaemia • Hypothermia • Hyperkalaemia, hypoglycaemia, and other metabolic abnormalities • Eclampsia • Intracranial haemorrhage The three major causes of cardiac arrest in pregnancy to remember are: • Obstetric haemorrhage • Pulmonary embolism • Sepsis leading to metabolic acidosis and septic shock

Question 248

Causes of obstetric haemorrhage

Answer 248

Obstetric haemorrhage is a major cause of severe hypovolaemia and cardiac arrest. Remember the causes of massive obstetric haemorrhage: • Ectopic pregnancy (early pregnancy) • Placental abruption (including concealed haemorrhage) • Placenta praevia • Placenta accreta • Uterine rupture

Question 249

Aortocaval Compression

Answer 249

Aortocaval Compression After 20 weeks gestation, the uterus is a significant size. When a pregnant woman lies on her back (supine), the mass of the uterus can compress the inferior vena cava and aorta. • The compression on the vena cava is most significant, as it reduces the blood returning to the heart (venous return). • This reduces the cardiac output, leading to hypotension. • In some instances, this can be enough to lead to the loss of cardiac output and cardiac arrest. • The vena cava is slightly to the right side of the body. The solution to aortocaval compression is to place the woman in the left lateral position, lying on her left side, with the pregnant uterus positioned away from the inferior vena cava. • This should relieve the compression on the inferior vena cava and improve venous return and cardiac output.

Question 250

Resuscitation in Pregnancy

Answer 250

Resuscitation in Pregnancy Several factors make resuscitation more complicated in pregnancy: ◊ Aortocaval compression ◊ Increased oxygen requirements ◊ Splinting of the diaphragm by the pregnant abdomen ◊ Difficulty with intubation ◊ Increased risk of aspiration ◊ Ongoing obstetric haemorrhage Resuscitation in pregnancy follows the same principles as standard adult life support, except for: ◊ A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta ◊ Early intubation to protect the airway ◊ Early supplementary oxygen ◊ Aggressive fluid resuscitation (caution in pre-eclampsia) ◊ Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR

Question 251

Delivery of the baby following resus of the mother

Answer 251

Delivery Immediate caesarean section is performed in a pregnant woman when: – There is no response after 4 minutes to CPR performed correctly – CPR continues for more than 4 minutes in a woman more than 20 weeks gestation The aim is to deliver the baby and placenta within 5 minutes of CPR commencing. – The operation is performed at the site of the arrest, for example, in A&E resus or on the ward. – The primary reason for the immediate delivery is to improve the survival of the mother. – Delivery improves the venous return to the heart, improves cardiac output and reduces oxygen consumption. – It also helps with ventilation and chest compressions. – Delivery increases the chances of the baby surviving, although this is secondary to the survival of the mother.

Question 252

What affect can drugs have on a fetus?

Answer 252

• FIRST TRIMESTER drugs can produce congenital malformations (teratogenesis) • period of greatest risk is from the third to the eleventh week of pregnancy. • SECOND and THIRD trimester drugs can affect the growth or functional development of the fetus, or they can have toxic effects on fetal tissues. • Drugs given shortly before term or during labour can have adverse effects on labour or on the neonate after delivery. • Benefit to the mother > than the risk to the fetus, • All drugs should be avoided if possible, during the first trimester.

Question 253

Common problematic drugs in pregnancy

Answer 253

• ACE inhibitors • Alcohol • Androgens • Anticonvulsants • CNS active drugs • Vitamin A • Tetracycline • Thalidomide • Coumarins • Immunosuppressive – e.g. methotrexate • Statins • Antibiotics – Trimethoprim first trimester • Live vaccines

Question 254

Importance of folate in pregnancy

Answer 254

• Folate is especially important during periods of frequent cell division and growth, such as infancy and pregnancy. • Folate deficiency hinders DNA synthesis and cell division, affecting hematopoietic cells and neoplasms the most because of their greater frequency of cell division. • Given 400 micrograms daily during pre-conception and the 1st Trimester. • Higher risk pregnancies get folic acid 5mg OD • Taking anti epileptics • Have a neural tube defect in mother/father • Mothered a previous child with a neural tube defect • DM • Sickle Cell Disease

Question 255

What anti hypertensives are used in pregnancy

Answer 255

• Labetalol , nifedipine & methyldopa • Target blood pressure during the antenatal period should be 135/85 mm Hg for women with hypertension during pregnancy

Question 256

Antibiotic treatment for UTI’s in pregnancy

Answer 256

Amoxicillin Nitrofurantoin (not in third trimester) Trimethoprim (not in first trimester) 7 days

Question 257

Management of vaginal candidiasis in pregnancy

Answer 257

Pregnancy can increase the risk of developing vaginal candidiasis – cottage cheese discharge with ++ itching • Management options: local treatment • Local – clotrimazole pessary e.g 500mg PV STAT • If pregnant: only local treatment can be used (cream or pessaries), as oral treatments are contraindicated in pregnancy.

Question 258

How is N&V treated in pregnancy?

Answer 258

Consider drug treatment with an anti-emetic if initial treatments such as dietary advice or rest have failed and the woman has persistent symptoms. • First-line: • antihistamine (oral cyclizine), or a phenothiazine (oral prochlorperazine), and reassess after 24 hours. • If the response to treatment is inadequate, the woman is not dehydrated, and there is no ketonuria: • Second-line: • Oral metoclopramide or oral ondansetron, should not be prescribed for longer than 5 days. • Reassess after 24 hours and seek specialist advice if the response to a second anti-emetic is poor

Question 259

Pain management in pregnancy

Answer 259

• Aspirin is not recommended in pregnancy • Low-dose aspirin sometimes recommended for women with recurrent pregnancy loss, clotting disorders and pre-eclampsia • Using high doses of aspirin during pregnancy can increase risk of congenital defects, premature closure of ductus arteriosus and bleeding in the brain of premature infants • Paracetamol first line – safe at the recommended dose – FIRST LINE CHOICE • Opioids – dihydrocodeine / codeine • Avoid NSAIDs during pregnancy particularly at term/3rd trimester – can cause premature closure of the Ductus Arteriosus

Question 260

Thyroid medication used in pregnancy

Answer 260

• Trimester specific ranges • Aim Euthyroidism prior to conception • Mild hypothyroidism – associated with an increased risk of miscarriage, preterm labour & neurodevelopmental delay • Thyroxine requirements increase by 30-50% from early pregnancy • Hyperthyroidism : use propylthiouracil in preference to carbimazole

Question 261

Recommend vaccines in pregnancy

Answer 261

• Inactivated seasonal flu vaccine &whooping cough vaccine (pertussis) - recommended • Covid -19 • tetanus vaccine NOT Live vaccines unless specific circumstances • Live vaccines include: • BCG (vaccination against tuberculosis) • MMR (measles, mumps and rubella) • oral polio (which forms part of the 6-in-1 vaccine given to infants) • oral typhoid • yellow fever

Question 262

Analgesia used when breast feeding

Answer 262

Paracetamol and Ibuprofen form the basis for safe analgesics for breastfeeding mothers. • CODEINE is contra-indicated during breastfeeding • If opioids used – monitor baby

Question 263

Active management of the third stage of labour

Answer 263

Active management ○ 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. ○ Active management is routinely offered to all women to reduce the risk of postpartum haemorrhage. It is also initiated if there is: ○ Haemorrhage ○ More than a 60-minute delay in delivery of the placenta (prolonged third stage)

Question 264

Classifications of post partum haemorrhage

Answer 264

Postpartum haemorrhage (PPH) refers to bleeding after delivery of the baby and placenta. It is the most common cause of significant obstetric haemorrhage, and a potential cause of maternal death. To be classified as postpartum haemorrhage, there needs to be a loss of: • 500ml after a vaginal delivery • 1000ml after a caesarean section It can be classified as: • Minor PPH – under 1000ml blood loss • Major PPH – over 1000ml blood loss Major PPH can be further sub-classified as: • Moderate PPH – 1000 – 2000ml blood loss • Severe PPH – over 2000ml blood loss It can also be categorised as: • Primary PPH: bleeding within 24 hours of birth • Secondary PPH: from 24 hours to 12 weeks after birth

Question 265

Four causes of postpartum haemorrhage

Answer 265

Causes There are four causes of postpartum haemorrhage, remembered using the “Four Ts” mnemonic: • T – Tone (uterine atony – the most common cause) • T – Trauma (e.g. perineal tear) • T – Tissue (retained placenta) • T – Thrombin (bleeding disorder)

Question 266

Risk factors for postpartum haemorrhage

Answer 266

Risk Factors • Previous PPH • Multiple pregnancy • Obesity • Large baby • Failure to progress in the second stage of labour • Prolonged third stage • Pre-eclampsia • Placenta accreta • Retained placenta • Instrumental delivery • General anaesthesia • Episiotomy or perineal tear

Question 267

Preventative measures of postpartum haemorrhage

Answer 267

Preventative Measures Several measures can reduce the risk and consequences of postpartum haemorrhage: • 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 268

Management of a postpartum haemorrhage

Answer 268

Management Postpartum haemorrhage is an obstetric emergency and needs to be managed by an experienced team, including senior midwives, obstetricians, anaesthetics, haematologists, blood bank staff and porters. 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 In severe cases, activate the major haemorrhage protocol. Each hospital will have a major haemorrhage protocol, which gives rapid access to 4 units of crossmatched or O negative blood.

Question 269

Mechanical treatment options for postpartum haemorrhage

Answer 269

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

Question 270

Medical treatment options for postpartum haemorrhage

Answer 270

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 271

Surgical treatment options for postpartum haemorrhage

Answer 271

Surgical treatment options involve: • 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 272

Secondary Postpartum Haemorrhage

Answer 272

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 273

Indication for elective caesarean

Answer 273

Indications for elective caesarean include: • Previous caesarean • Symptomatic after a previous significant perineal tear • Placenta praevia • Vasa praevia • Breech presentation • Multiple pregnancy • Uncontrolled HIV infection • Cervical cancer

Question 274

Layers of the abdomen that need to be dissected during a caesarean

Answer 274

The layers of the abdomen that need to be dissected during a caesarean are: • Skin • Subcutaneous tissue • Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles) • Rectus abdominis muscles (separated vertically) • Peritoneum • Vesicouterine peritoneum (and bladder) – the bladder is separated from the uterus with a bladder flap • Uterus (perimetrium, myometrium and endometrium) • Amniotic sac

Question 275

Risks associated with having spinal anaesthetic

Answer 275

Risks associated with having an anaesthetic: • Allergic reactions or anaphylaxis • Hypotension • Headache • Urinary retention • Nerve damage (spinal anaesthetic) • Haematoma (spinal anaesthetic) • Sore throat (general anaesthetic) • Damage to the teeth or mouth (general anaesthetic)

Question 276

Measures to reduce the risks during caesarean section

Answer 276

Measures to reduce the risks during caesarean section are: • H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure • Prophylactic antibiotics during the procedure to reduce the risk of infection • Oxytocin during the procedure to reduce the risk of postpartum haemorrhage • Venous thromboembolism (VTE) prophylaxis with low molecular weight heparin 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.

Question 277

Complications of a caesarean

Answer 277

There is a risk of aspiration pneumonitis during caesarean section, caused by acid reflux and aspiration during the prolonged period lying flat. Generic surgical risks: • Bleeding • Infection • Pain • Venous thromboembolism Complications in the postpartum period: • Postpartum haemorrhage • Wound infection • Wound dehiscence • Endometritis Damage to local structures: • Ureter • Bladder • Bowel • Blood vessels Effects on the abdominal organs: ® Ileus ® Adhesions ® Hernias Effects on future pregnancies: • Increased risk of repeat caesarean • Increased risk of uterine rupture • Increased risk of placenta praevia • Increased risk of stillbirth Effects on the baby: • Risk of lacerations (about 2%) • Increased incidence of transient tachypnoea of the newborn

Question 278

Two key causes of sepsis in pregnancy

Answer 278

Two key causes of sepsis in pregnancy are: 1. Chorioamnionitis 2. Urinary tract infections

Question 279

Chorioamnionitis

Answer 279

Chorioamnionitis • 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. • Chorioamnionitis can be caused by a large variety of bacteria, including gram-positive bacteria, gram-negative bacteria and anaerobes

Question 280

Investigations for suspected maternal sepsis

Answer 280

Investigations Arrange blood tests for patients with suspected sepsis: • Full blood count to assess cell count including white cells and neutrophils • U&Es to assess kidney function and for acute kidney injury • LFTs to assess liver function and as a possible source of infection (e.g. acute cholecystitis) • CRP to assess inflammation • Clotting to assess for disseminated intravascular coagulopathy (DIC) • Blood cultures to assess for bacteraemia • Blood gas to assess lactate, pH and glucose Additional investigations can be helpful based on the suspected source of infection: • Urine dipstick and culture • High vaginal swab • Throat swab • Sputum culture • Wound swab after procedures • Lumbar puncture for meningitis or encephalitis

Question 281

Amniotic fluid embolism

Answer 281

• 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. • The mortality rate is around 20% or above.

Question 282

Presentation of amniotic fluid embolism

Answer 282

Presentation Amniotic fluid embolisation usually 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: ○ Shortness of breath ○ Hypoxia ○ Hypotension ○ Coagulopathy ○ Haemorrhage ○ Tachycardia ○ Confusion ○ Seizures ○ Cardiac arrest

Question 283

Management of amniotic fluid embolism

Answer 283

Management The overall management of amniotic fluid embolism is supportive. There are no specific treatments. Amniotic fluid embolism is a medical emergency – get help immediately. It requires the input of experienced obstetricians, medics, anaesthetics, intensive care teams and haematologists. They are likely to need transfer to the intensive care unit. The initial management of any acutely unwell patient is with an ABCDE approach, assessing and treating: § A – Airway: Secure the airway § B – Breathing: Provide oxygen for hypoxia § C – Circulation: IV fluids to treat hypotension and blood transfusion in haemorrhage § D – Disability: Treat seizures and consider other neurological deficits § E – Exposure Cardiopulmonary resuscitation and immediate caesarean section are required if cardiac arrest occurs.

Question 284

Uterine rupture

Answer 284

• 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 285

The main risk factor for uterine rupture

Answer 285

Risk factors The main risk factor for uterine rupture is a previous caesarean section. • The scar on the uterus becomes a point of weakness, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin). It is extremely rare for uterine rupture to occur in a patient that is giving birth for the first time.

Question 286

Presentation of uterine rupture

Answer 286

Presentation 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 287

Management of uterine rupture

Answer 287

Management 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 288

In the days after a baby is born what monitoring is done for baby and mother?

Answer 288

In the days after delivery they will have: • Analgesia as required • Help establishing breast or bottle-feeding • Venous thromboembolism risk assessment • Monitoring for postpartum haemorrhage • Monitoring for sepsis • Monitoring blood pressure (after pre-eclampsia) • Monitoring recovery after a caesarean or perineal tear • Full blood count check (after bleeding, caesarean or antenatal anaemia) • Anti-D for rhesus D negative women (depending on the baby’s blood group) • Routine baby check

Question 289

What is discussed in a six week post natal check for mum?

Answer 289

Six-Week Postnatal Check A routine six-week postnatal appointment is commonly offered by GP practices to check how the mother is doing. It is usually done at the same time as the six-week newborn baby check. The topics that are covered at the six-week check include: § General wellbeing § Mood and depression § Bleeding and menstruation § Scar healing after episiotomy or caesarean § Contraception § Breastfeeding § Fasting blood glucose (after gestational diabetes) § Blood pressure (after hypertension or pre-eclampsia) § Urine dipstick for protein (after pre-eclampsia)

Question 290

Post partum menstruation and bleeding

Answer 290

In the period shortly after birth, there will be vaginal bleeding as the endometrium initially breaks down, then returns to normal over time. • This is a mix of blood, endometrial tissue and mucus, and is called lochia. • Initially, it will be a dark red colour and over time will turn brown, and become lighter in flow and colour. • Tampons should be avoided during this period, as they carry a risk of infection. • Bleeding should settle within six weeks.

Question 291

How does breast feeding affect menstruation?

Answer 291

Breastfeeding releases oxytocin, which can cause the uterus contract, leading to slightly more bleeding during episodes of breastfeeding. • This is normal. • 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 292

Contraception after child birth

Answer 292

Contraception After Childbirth's 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). A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than four weeks after birth (UKMEC 1), but not inserted between 48 hours and four weeks of delivery (UKMEC 3).

Question 293

Postpartum endometritis

Answer 293

• Endometritis refers to inflammation of the endometrium, usually caused by infection. • It can occur in the postpartum period, as infection is introduced during or after labour and delivery. • The process of delivery opens the uterus to allow bacteria from the vagina to travel upwards and infect the endometrium. • Endometritis occurs more commonly after caesarean section compared with vaginal delivery. ○ Prophylactic antibiotics are given during a caesarean to reduce the risk of infection. • Endometritis can be caused by a large variety of gram-negative, gram-positive and anaerobic bacteria. ○ It can also be caused by sexually transmitted infections such as chlamydia and gonorrhoea. • When endometritis occurs unrelated to pregnancy and delivery, it is usually part of pelvic inflammatory disease, which is covered elsewhere.

Question 294

Symptoms of postpartum endometritis

Answer 294

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

Question 295

How is postpartum endometritis diagnosed and managed?

Answer 295

Diagnosis and Management Investigations to help establish the diagnosis include: ○ Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors) ○ Urine culture and sensitivities Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis). Septic patients will require hospital admission and the septic six, including blood cultures and broad-spectrum IV antibiotics (according to local guidelines). ○ A combination of clindamycin and gentamicin is often recommended. ○ Blood tests will show signs of infection (e.g. raised WBC and CRP). Patients presenting with milder symptoms and no signs of sepsis may be treated in the community with oral antibiotics. ○ A typical choice of broad-spectrum oral antibiotic might be co-amoxiclav, depending on the risk of chlamydia and gonorrhoea.

Question 296

What is retained products of conception?

Answer 296

Retained products of conception refers to when pregnancy-related tissue (e.g. placental tissue or fetal membranes) remain in the uterus after delivery. • It can also occur after miscarriage or termination of pregnancy. Placenta accreta is a significant risk factor for retained products of conception.

Question 297

Presentation of retained products of conception

Answer 297

Presentation Retained products of conception may be present in patients without any suggestive symptoms. It may present with: • Vaginal bleeding that gets heavier or does not improve with time • Abnormal vaginal discharge • Lower abdominal or pelvic pain • Fever (if infection occurs)

Question 298

How is retained products of conception diagnosed?

Answer 298

Diagnosis Ultrasound is the investigation of choice for confirming the diagnosis.

Question 299

Now is retained products of conception managed?

Answer 299

The standard management of postpartum retained products of conception is to remove them surgically. ○ Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic. ○ The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping). ○ The procedure may be referred to as “dilatation and curettage”.

Question 300

Two key complications of retained products of conception

Answer 300

○ Two key complications are: ○ Endometritis ○ Asherman’s syndrome Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus. ○ 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. ○ There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. ○ This can lead to infertility.

Question 301

What is Ashermans syndrome?

Answer 301

Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus. ○ 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. ○ There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. ○ This can lead to infertility.

Question 302

Postpartum anaemia

Answer 302

Postpartum anaemia is defined as a haemoglobin of less than 100 g/l in the postpartum period. • Anaemia is common after delivery due to acute blood loss. Most women lose some blood during delivery. • In complicated deliveries, caesarean sections and postpartum haemorrhage, women can lose upwards of 1.5 litres of blood. It is essential to optimise the treatment of anaemia during pregnancy, so that women have optimal haemoglobin and iron stores before delivery.

Question 303

Management of postpartum anaemia

Answer 303

Management A full blood count is checked the day after delivery if there has been: • Postpartum haemorrhage over 500ml • Caesarean section • Antenatal anaemia • Symptoms of anaemia Treatment of anaemia is based on individual factors and preferences alongside local guidelines. As a rough guide (local policies will vary): • Hb under 100 g/l – start oral iron (e.g. ferrous sulphate 200mg three times daily for three months) • Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject) • Hb under 70 g/l – blood transfusion in addition to oral iron

Question 304

Why is active infection a contraindication to an iron infusion?

Answer 304

Active infection is a contraindication to an iron infusion. Many pathogens “feed” on iron, meaning that intravenous iron can lead to proliferation of the pathogen and worsening infection. It is important to wait until the infection is treated before giving an iron infusion.

Question 305

Types of postnatal mental health issues

Answer 305

There is a spectrum of postnatal mental health illness: • Baby blues is seen in the majority of women in the first week or so after birth • Postnatal depression is seen in about one in ten women, with a peak around three months after birth • Puerperal psychosis is seen in about one in a thousand women, starting a few weeks after birth

Question 306

Baby blues

Answer 306

Baby Blues Baby blues affect more than 50% of women in the first week or so after birth, particularly first-time mothers. It presents with symptoms such as: • Mood swings • Low mood • Anxiety • Irritability • Tearfulness Baby blues may be the result of a combination of: ○ Significant hormonal changes ○ Recovery from birth ○ Fatigue and sleep deprivation ○ The responsibility of caring for the neonate ○ Establishing feeding ○ All the other changes and events around this time Symptoms are usually mild, only last a few days and resolve within two weeks of delivery. No treatment is required.

Question 307

Postnatal depression

Answer 307

Postnatal Depression Postnatal depression is similar to depression that occurs outside of pregnancy, with the classic triad of: • Low mood • Anhedonia (lack of pleasure in activities) • Low energy Typically, women are affected around three months after birth. Symptoms should last at least two weeks before postnatal depression is diagnosed. Treatment is similar to depression at other times: ○ Mild cases may be managed with additional support, self-help and follow up with their GP ○ Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy ○ Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit

Question 308

Postnatal depression treatment

Answer 308

Treatment is similar to depression at other times: ○ Mild cases may be managed with additional support, self-help and follow up with their GP ○ Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy ○ Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit

Question 309

What is the screening tool for post natal depression?

Answer 309

Edinburgh Postnatal Depression Scale 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.

Question 310

Puerperal Psychosis

Answer 310

Puerperal Psychosis Puerperal psychosis is a rare but severe illness that typically has an onset between two to three weeks after delivery. Women experience full psychotic symptoms, such as: • Delusions • Hallucinations • Depression • Mania • Confusion • Thought disorder

Question 311

Puerperal Psychosis treatment

Answer 311

Women with puerperal psychosis need urgent assessment and input from specialist mental health services. Treatment is directed by specialist services, and may involve: ○ Admission to the mother and baby unit ○ Cognitive behavioural therapy ○ Medications (antidepressants, antipsychotics or mood stabilisers) ○ Electroconvulsive therapy (ECT)

Question 312

Neonatal abstinence syndrome

Answer 312

SSRI antidepressants taken during pregnancy can lead to neonatal abstinence syndrome (also known as neonatal adaptation syndrome). It presents in the first few days after birth with symptoms such as irritability and poor feeding. Neonates are monitored for this after delivery. Supportive management is usually all that is required.

Question 313

Postpartum thyroiditis

Answer 313

Postpartum thyroiditis is a condition where there are changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease. • It can involve thyrotoxicosis (hyperthyroidism), hypothyroidism, or both. Over time the thyroid function returns to normal, and the patient will become asymptomatic again. • A small portion of women will remain hypothyroid and need long-term thyroid hormone replacement.

Question 314

Pathophysiology of postpartum thyroiditis

Answer 314

Pathophysiology The cause of postpartum thyroiditis is not clear. • The leading theory is that pregnancy has an immunosuppressant effect on the mother’s body, to prevent her from rejecting the fetus. • Once delivery has occurred, there can be an exaggerated rebound effect, with increased immune system activity and expression of antibodies. • This may include antibodies that affect the thyroid gland, for example, thyroid peroxidase antibodies. • These antibodies cause inflammation of the thyroid gland, leading to over or under activity.

Question 315

General stages of thyroiditis in postpartum women

Answer 315

Stages There is a typical pattern of postpartum thyroiditis. Not all women will follow this pattern. There are three stages: 1. Thyrotoxicosis (usually in the first three months) 2. Hypothyroid (usually from 3 – 6 months) 3. Thyroid function gradually returns to normal (usually within one year)

Question 316

Signs and symptoms of postpartum thyrotoxicosis

Answer 316

Signs and Symptoms The signs and symptoms of thyrotoxicosis (hyperthyroidism) include: ○ Anxiety and irritability ○ Sweating and heat intolerance ○ Tachycardia ○ Weight loss ○ Fatigue ○ Frequent loose stools

Question 317

Signs and symptoms of postpartum hypothyroidism

Answer 317

The signs and symptoms of hypothyroidism include: • Weight gain • Fatigue • Dry skin • Coarse hair and hair loss • Low mood • Fluid retention (oedema, pleural effusions, ascites) • Heavy or irregular periods • Constipation

Question 318

Management of post partum thyroiditis

Answer 318

Management There should be a low threshold for testing thyroid function in women presenting with suggestive symptoms, particularly postnatal depression. Thyroid function tests are performed 6 – 8 weeks after delivery. Patients with abnormal thyroid function tests in the postpartum period require referral to an endocrinologist for specialist management. Typical treatment is with: □ Thyrotoxicosis (hyper): symptomatic control, such as propranolol (a non-selective beta-blocker) □ Hypothyroidism: levothyroxine Symptoms and thyroid function tests are monitored, and treatment is altered or stopped as the condition changes and improves. Women with postpartum thyroiditis require annual monitoring of thyroid function tests, even after the condition has resolved. □ Monitoring is to identify those that go on to develop long-term hypothyroidism.

Question 319

Sheehans syndrome

Answer 319

Sheehan’s syndrome is a rare complication of post-partum haemorrhage, where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland. • Low blood pressure and reduced perfusion of the pituitary gland leads to ischaemia in the cells of the pituitary, and cell death. Sheehan’s syndrome only affects the anterior pituitary gland. • Therefore, hormones produced by the posterior pituitary are spared. Blood Supply The anterior pituitary gets its blood supply from a low-pressure system called the hypothalamo-hypophyseal portal system. • This system is susceptible to rapid drops in blood pressure. The posterior pituitary gets a good blood supply from various arteries, and is therefore not susceptible to ischaemia when there is a drop in blood pressure.

Question 320

What hormones are affected by Sheehan’s syndrome?

Answer 320

The anterior pituitary releases • Thyroid-stimulating hormone (TSH) • Adrenocorticotropic hormone (ACTH) • Follicle-stimulating hormone (FSH) • Luteinising hormone (LH) • Growth hormone (GH) • Prolactin Therefore these hormones are affected by Sheehans syndrome, where as The posterior pituitary releases (not affected by Sheehan’s syndrome): ○ Oxytocin ○ Antidiuretic hormone (ADH) So not affected by Sheehan’s syndrome

Question 321

Presentation of Sheehans syndrome

Answer 321

Presentation Sheehan’s syndrome causes a lack of the hormones produced by the anterior pituitary, leading to signs and symptoms of: § Reduced lactation (lack of prolactin) § Amenorrhea (lack of LH and FSH) § Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH) § Hypothyroidism with low thyroid hormones (lack of TSH)

Question 322

Management of Sheehans syndrome

Answer 322

Management Sheehan’s syndrome will be managed under the guidance of a specialist endocrinologist. It will involve replacement for the missing hormones: □ Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause) □ Hydrocortisone for adrenal insufficiency □ Levothyroxine for hypothyroidism □ Growth hormone