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OBSTETRICS E L L E N D U N L O P E D U N L O P 1 6 @ Q U B . AC . U K • Pregnancy timeline • Conditions in pregnancy • Antenatal care • Labour TOPICS • Post natal care • Emergencies • OSCE tips • MCQsCLINICS TIMELINE/APPOINTMENTS PET = aspirin GDM = OGTT at 24- 28w (16w if previous • G = gravida = how many pregnancies GDM) VTE = LMWH • P = parity = how many births (>24w) Rh neg =Anti-D at 28, 34w (+ if any • Appointments sensitising events) – 10-12w = Booking appt.Dating scan,risk assessments BP,urinalysis,SFH at – 20w = anomaly scan all appointments – 28,34,36w = midwife appt = FHR,SFH (tape measurement) Growth scans maximum 2 weekly if – Consultant led mothers will have extra appointments – growth scans needed Dating = <14w – – 40w = may be offered sweep – 41w = offered IOL (sooner if any risks) crown-rump length Late booker (>14w) = head (BPD), abdominal circumference,femur lengthSCREENING Don’t routinely screen for group B streptococcus Anaemia in pregnancy Booking <110 • Done at booking appointment 28w <105 • Routine screening for: Postnatal <100 – HIV – Hepatitis B – Syphilis – Blood group including Rhesus status All UTI need treated, even if asymptomatic – Rubella immunity 7 day course of abx – Anaemia  iron supplements Avoid trimethoprim 1 st trimester,nitrofurantoin – Urinalysis – asymptomatic bacteruria rd 3 trimester FOLIC ACID From conception • Most people = 400 micrograms (ideally prior to conleast 12wuntil at • High dose = 5mg • Previous baby with NTD • Either parent affected by NTD • Strong FHx of NTD • BMI >30 Often get combined • Diabetes vitamin D & folic acid • Coeliac disease = pregnacare • Thalassaemia • Multiple pregnancy • Medications – taking antiepilepticsLIFESTYLE/ADVICE • Foods to avoid – VitaminA (liver,pate) – Unpasteurised dairy/blue cheese – listeriosis – Alcohol & smoking (good time to quit,will be screened for CO levels at booking) • Vaccines – Flu – Whooping cough (Pertussis) – from 16w – Covid – No live vaccines – eg – MMR • Continue to exercise • Flying = increased riskVTE GENETIC SCREENING Combined test 11-14w:USS and bloods Further tests (if screening positive) – higher than 1 in 150 risk Increased risk: • >6mm nuchal CVS:Chorionic villous sampling • <15w translucency • Sample placental blood to assess fetal DNA • Increased BhCG • Decrease PAPP-A Quadruple test 14-20w:bloods NIPT:Non-invasive prenatal testing • Free fetal DNA in maternal blood Increased risk: • Not widely available on NHS.Aka Harmony • Increased BhCG, Inhibin-A test • DecreasedAFP, oestradiolCONDITIONS IN PREGNANCYCHRONIC CONDITIONS IN PREGNANCY • Epilepsy – 5mg folic acid,lowest effective antiepileptic dose – Mgood seizure control pre-conceptiono stress,lack of sleep,hormonal changes.Aim for – Seizures most likely intra/post-partum – Medications – avoid valproate (NTDs),phenytoin (cleft lip/palate) • Hypothyroidism – Most need increased levothyroxine dose – If not controlled = anaemia,SGA,miscarriageHYPERTENSION • BP >140/90 • Before 20w = essential HTN • >20w = gestational HTN.With proteinuria = pre-eclampsia • If onACEi/ARB prior to pregnancy,switch to beta blocker (CI in asthma) or nifedipine PRE-ECLAMPSIA • Hypertension with proteinuria = indicates end-organ (renal dysfuction) • Multisystem disorder – placenta can be affected = doppler & fetal growth monitored Complications Eclampsia • HELLP (↓ Hb,↑ Symptoms Management • Seizure LFTs (excluding • Headache (frontal) • Labetalol for HTN • IV MgSO4 given to ALP),↓ plt) • Visual flashes • Cons led care – 2 weekly • Epigastric (RUQ) USS (growth,AFI, treat – protective for • Stroke doppler) baby and mother • Renal failure pain • Admit if uncontrollable • Emergency delivery • DIC • Oedema BP (risk of eclampsia) – needed • Placental • Brisk reflexes consider delivery • Given until 24h post- abruption • Reduced urine delivery or seizure • Stillbirth output • Risk of pulmonary • IUGR • IUGR oedema – fluid restrict DIABETES Neonatal complications • Macrosomia – risk of shoulder Management Risks & prophylaxis • Malformations:high dose folic dystocia • Stop oral hypoglycaemics acid • Hypoglycaemia after birth – • Can continue metformin • Worsening retinopathy: monitoring of sugars,may need • Insulin safe and used screening at 28w NICU • LGA or SGA • Birth 37-39w • PET:aspirin 75mg from 12w • Respiratory distress syndrome • IOL if not in labour by 39w • Neonatal growth:close • Jaundice • Sliding scale insulin during monitoring • Congenital heart disease labour GESTATIONAL DIABETES (GDM) Risks OGTT Risks of GDM • BMI >30 • Fasting >5.6 mmol/L Stillbirth • Previous GDM *** • 2hr >7.8 mmol/L Macrosomia • Previous macrosomic baby Amniotic fluid excess = • Ethnic origin polyhydramios • 1 degree relative with any Shoulder dystocia diabetes – includes GDM Management Hypoglycaemia (neonatal) If fasting <7 mmol/L • Also will screen at any • Diet & exercise – strict diet & gestation if LGA or check sugars regularly,keep diary polyhydramnnios Post natal • Metformin • Sugar control should return to Screening • Insulin normal – dietary restrictions • OGTT at 24-28w – most likely limited to develop in 2 trimester If fasting >7 mmol/L • 6w postnatal glucose check • ***16w if previous GDM • Insulin • Long term higher risk ofT2DMANTENATAL CARE GROWTH CHART • Each women’s is different – based on BMI, ethnicity,previous baby’s weights • Low risk women (MW led) = SFH • Centile lines = trend of growth – should follow centiles • Concern if falling across centiles/static growth – refer for USS • AFI • Growth – BPD,HC,AC,FL • Umbilical artery doppler SGA AND IUGR IUGR Cause: SGA • Placental issues - PET,diabetes,smoking, Growth <10 centile alcohol May just be constitutionally small – no • Malnutrition underlying pathology • Infections – CMV,rubella • Congenital – trisomies,Turner’s syndrome – Cause:maternal BMI (low),ethnicity fetal medicine referral Management: Other signs: • Growth & doppler every 2 weeks • Reduced fetal movements • CTG monitoring to ensure no fetal • Reduced amniotic fluid distress/adverse features • Abnormal umbilcal artery doppler (absent or • If normal,continue with regular appointments reduced) • If abnormal,delivery • Abnormal CTG IUGR MANAGEMENT • 2 weekly growth scan • <32w with abnormal doppler = daily CTG – If abnormal = deliver • If >34w with abnormal doppler = deliver If pre-term delivery = corticosteroids & MgSO4 needed HYPEREMESIS GRAVIDARUM PUQE score • Some vomiting in pregnancy is very common • Prolonged vomiting causing dehydration or >5% pre-pregnancy weight loss • Due to high BhCG = worse in molar and twin pregnancy Management Investigations • Antiemetics (PCOM = prochlorperazone, • U&E (K) cyclizine,ondansetron,metoclopramide – • Urinalysis (ketones) only for a few days) • FBC • Fluid replacement • Bone profile • Pabrinex • USS • LMWH,TEDS OBSTETRIC CHOLESTASIS • Reduced bile acid flow from liver • Usually develops >28w • Cause unclear – possible link to hormonal changes.More common in SouthAsian women • ↑ bile acids = ↑ itch (palms & soles) Investigations Management Deranged LFTs Ursodeoxycholic acid – treats cause Raised bile acids Emollients (calamine lotion) and antihistamines (chlorphenamine) for itch MULTIPLE PREGNANCY • Classified according to how many (mono/di) placentas (chorionic) /amniotic sacs (amnionic) =mono/di MCMA/DCDA • MCMA twins most high risk Twin-twin transfusion syndrome Monochorionic twins • Donor twin:volume depleted = IUGR,anaemia • Recipient twin:fluid overload = heart failure,polycythaemia,LGA • Treatment = laser to cut anastomosis – only done by specialists (London) REDUCED FETAL MOVEMENT • Movement felt by 24w,pattern by 28w • Any change in movement needs reported – reduce risk stillbirth Doppler of fetal heartbeat • CTG monitoring if FH present • USS immediately if FH not present RUPTURE OF MEMBRANES (ROM) Definitions • SROM:spontaneous ROM – Investigations Management can be start of labour (>37w) • Sterile speculum – pooling in • Erythromycin for 10 days – or Generally given 24h to go into posterior fornix until labour (prevent labour if no concerns • Amnisure – presence of chorioamnionitis) Oxytocin infusion to induce amniotic fluid • Regular fetal monitoring – USS, labour • Fetal fibronectin/partosure – CTG likelihood of going in to labour • Monitor temperature,WBC, • PROM:premature (<37w) CRP ROM Should not do digital examination • Corticosteroids if preterm • PPROM:preterm,prelabour – risk of introducing infection ROMMECONIUM STAINED LIQUOR • Fetal distress during labour causes loss of control of anal sphincter and meconium is passed prematurely.May also see fetal distress on CTG • Small amount during labour = light green/yellow – continue labour • Dark green or fetal distress = immediate delivery • Black = emergency = deliver • Inform paediatrics – risk of aspiration and meconium aspiration syndromePRETERM LABOUR • Labour <37w Management: • Steroids – 2 doses betamethasone (corticosteroids) 12mg IM 24h apart – Matures fetal lungs = decreased risk RDS • MgSO4 – Neuroprotective – Aim to give <12h before birth • Nifedipine – Can be used as tocolysis – do try to delay deliveryOTHER CAUSES OF ABDOMINAL PAIN Placental abruption Uterine rupture Pelvic girdlepain Gallstones Appendicitis UTI ANTEPARTUM HAEMORRHAGE • Bleeding after 24w - before this is called threatened miscarriage Painless bleeding Painful bleeding Placenta praevia Placental abruption • Low placenta,covers cervical os • Placenta sheared from uterine wall • High risk haemorrhage • Woody,tender uterus (may be concealed = no • Diagnose:TVUSS,if previous scar – eg – CS,rule active bleeding) out placenta accrete • Sudden onset – pain,maternal shock,fetal distress • Cannot labour = CS required • Require EMCS Vasa praevia Uterine rupture • Fetal blood vessels exposed,cover cervical os • Usually during labour – due to contractions • Bleeding onset after ROM • Risk:previous CS scar = weakness on uterus • Fetal distress = eg – decelerations on CTG • Fetal distress • If known = ELCS,if unknown = EMCS • EMCSLABOUR Term = 37w- 42w STAGES Preterm = <37w Delayed cord st clamping – 1 1 stage 2nd stage minute • Effacement and dilatation of • Birth of baby cervix to 10cm • Delayed = pushing >2h (first Latent = 0-4cm pregnancy) or >1h • Can be prolonged (multiparous) • 0.5cm/hour rd Aim for 3-4 contractions in 10 3 stage minutes,lasting 60 seconds • Delivery of placenta Active = 4-10cm • Physiological – up to 60 • 1cm/hour minutes • Active – up to 30 minutes. Controlled cord traction & IM Failure to progress = 3Ps oxytocin = reduced risk of • Passage = cephalo-pelvic disproportion PPH • Passenger = fetal malpresentation • Power = in-coordinate contractions INDUCTION OF LABOUR Ripening agents Vaginal prostaglandins • Pessary for 24h / gel Bishop score Balloon ripening (Foley) • Position • Where vaginal prostaglandins not suitable – previous CS or para ≥ 3) • Consistency • Effacement ARM = artificial rupture of membranes • Dilation of cervix • With oxytocin infusion (for contractions) • Station of fetal head • Only if cervix dilated • >8 = favourable for IOL • <8 = unfavourable for IOL = cervical ripening agents needed Complications • Uterine hyperstimulation - >5 contractions in 10 minutes,lasting >2 mins • Stop oxytocin,tocolytics,consider fluid bolus,maternal L lateral position, may need CS POST-PARTUM HAEMORRHAGE Oxytocin in 3rd stage labour decreases PPH • Primary – within 24h of labour risk • Secondary – up to 12w post natal • Vaginal birth = >500ml,CS = >1000ml Causes = 4Ts Tears • Tone – uterine atony.Most common.Fundal massage,oxytocin 1 Superficial – skin • Tissue – retained placenta/membranes.Check they are complete,may need nd manual removal (theatre) 2 rdrineal Muscle • Trauma – check perineum,repair if needed 3 anal Sphincter 4 rectal Mucosa • Thrombin – clotting disorder (check Hx,coag screen) MANAGEMENT (c)ABCDE assessment Uterine massage Oxytocin IM / Ergometrine IM Oxytocin infusion Carborprost Consider Misoprostol • MHP – group & Xmatch,1:1:1 Tranexamic acid IV RBC:FFP:Plts Bimanual compression,theatre • Wide bore cannulae • Senior help – obstetrician,midwife, anaesthetist • SRC insertion – full bladder can prevent uterus contracting Surgical management • Risk of DIC • Intrauterine balloon • B Lynch suture • Uterine artery embolisation • HysterectomyEMERGENCIES SHOULDER DYSTOCIA Anterior shoulder obstructed behind symphysis pubis = pressure on branchial plexus Complications • Erbs palsy C5/C6 • Fethl distress & death • 4 degree tear • PPH Management • Suprapubic pressure,episiotomy, McRobert’s maneouvre,CS CORD PROLAPSE Risks • Abnormal lie • PPROM or afterARM – decreased amniotic fluid Presentation • Fetal distress on CTG Management • Don’t touch cord – keep it wet • Mother on all 4s EMCSAMNIOTIC FLUID EMBOLISM • Amniotic fluid enters maternal circulation = distress and arrest • Occurs around time/after delivery • Sudden onset maternal SOB,hypoxia,hypotension,cardiac arrestPOST NATALPOST NATAL CARE • Mastitis:continue to breastfeed,if not resolving abx may be needed – flucloxacillin • 6 week post-natal check by GP • Mental health – Baby blues – mild,reassure – Depression – SSRI,CBT – Puerperal psychosis – harm self/baby,don’t bond.Mother and baby unit • Retained products of conception – if placenta not complete can get endometritis (basically PID but due to retained products) – Given misoprostol & antibiotics,interval scan to check resolvedOSCES • Obstetric history – Always ask about fetal movement,PV bleeding/ROM,abdominal pain,PET symptoms,mental health + if they feel safe at home • Pregnant abdomen examination – SFH – tape numbers facing down.Gestation = cm +/-2 – Lie,presentation,position,engagement – Auscultate over anterior shoulder,palpate maternal pulseOTHER POINTS • HIV +ve mothers usually require CS birth,can have vaginal birth if low viral load • ECV = external cephalic version for breech at 36w (nulliparous),37w (multiparous) • Lithium can cause cardiac abnormalities (Ebstein anomaly) • MgSO4 can cause respiratory depression = reversal with calcium gluconate • No NSAIDs in pregnancy – can cause cardiac abnormalitiesPREVIOUS OSCES • PV bleeding history • Bimanual & speculum • Pre-eclampsia history • PPHABCDE • Growth chart plotting/interpretation • Genetic counselling/testing • Pre-conception diabetes counselling • Data interpretation - HELLPMCQSMCQS • Which one of the following patterns would you expect to see in positive quadruple test screening forT21 – A:Increased oestriol,inhibinA& bHCG;decreasedAFP – B:IncreasedAFP,inhibinA& bHCG;decreased oestriol – C:Increased inhibinA & bHCG;decreased oestriol,AFP – D:Increased oestriol &AFP;decreased inhibinA & bHCG – E:IncreasedAFP;decreased inhibinA,bHCG,oestriol• Which one of the following is an indication for an OGTT – A:Spanish origin – B:BMI 27 – C:Age 36 – D:Father withT2DM – E:Previous baby weighing 3kg• A 26 year old lady is trying to conceive.Her BMI is 29,she has a history of coeliac disease and she is taking iron supplements for anaemia,which dose of folic acid should she be taking? – A:400 micrograms – B:4 grams – C:500 micrograms – D:5 grams – E:None• Mrs Smith attended her routine 28 week appointment.Her BP was 155/98 mmHg.There was no proteinuria.She feels well and does not take any medications outside of pregnancy.What is the most likely diagnosis? – A:essential hypertension – HELLP syndrome – Pre-eclampsia – Gestational hypertension – Normal change in pregnancy• A 24 year old woman is planning to conceive.She takes salbutamol & betamethasone inhalers for asthma and sodium valproate for epilepsy.She also takes paracetamol and codeine for back pain.Which of her medications could be teratogenic if she continued to take it during pregnancy? – A:betamethasone – B:codeine – C:paracetamol – D:salbutamol – E:sodium valproate• What is the most appropriate initial investigation for a woman of 35 weeks gestation presenting with reduced fetal movement? – A:doppler of fetal heart – B:CTG – C:USS – D:urinalysis – E:blood pressure• A 31 year old woman of 34 weeks gestation presents with severe abdominal pain.Fetal movements have been normal until the onset of pain.There is no vaginal bleeding reported but the pain is worsening.On examination her uterus is tender,firm and woody on palpation.High blood pressure was recorded on her last midwife appointment.Which diagnosis is most likely? – A:cholecystitis – B:placental abruption – C:pre-eclampsia – D:pre-term labour – E:urinary tract infection• A woman on the labour ward has a 1500ml blood loss 2 hours following a vaginal delivery. Which is the definitive management of this diagnosis? – A:uterine artery embolisation – B:B lynch suture – C:bimanual compression – D:hysterectomy – E:blood transfusion