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ROAD TO FINALS EPISODE 2: OBSTETRICS Priyanka Iyer ST2 O&G Newham University Hospital 24 April 2024TOPICS 1. Bleeding in pregnancy: <24 weeks and >24 weeks (APH) 2. Labour: Normal labour, Preterm labour, Induction of labour 3. Complications in labour: Breech presentation, Shoulder dystocia, Cord Prolapse, Instrumental delivery, PPH 4. Conditions in pregnancy: Pre-eclampsia, Gestational and pre-existing diabetes, Itching in pregnancy, Hyperemesis GravidarumBLEEDING IN PREGNANCYBLEEDING IN PREGNANCY MCQ 1 A 25-year-old woman at 25 weeks gestation presents with constant lower abdominal pain and a small amount of vaginal bleeding. On examination blood pressure is 90 / 60 mmHg. What is the most likely diagnosis? A. Ectopic pregnancy B. Threatened miscarriage C. Placental abruption D. Placenta praevia E. Molar pregnancyBLEEDING IN PREGNANCY MCQ 1 A 25-year-old woman at 25 weeks gestation presents with constant lower abdominal pain and a small amount of vaginal bleeding. On examination blood pressure is 90 / 60 mmHg. What is the most likely diagnosis? A. Ectopic pregnancy B. Threatened miscarriage C. Placental abruption D. Placenta praevia E. Molar pregnancyBLEEDING IN PREGNANCY MCQ 2 A young woman at 30 weeks gestation, presents with painless bright red vaginal bleeding, she reports two previous scanty episodes of painless vaginal bleeding, but feels that this episode has been much more severe. Obstetric examination finds a cephalic presentation with high presenting part. The uterus is non-tender. The cervical os is closed and the cervix appears normal. A. Ectopic pregnancy B. Threatened miscarriage C. Placental abruption D. Placenta praevia E. Molar pregnancyBLEEDING IN PREGNANCY MCQ 2 A young woman at 30 weeks gestation, presents with painless bright red vaginal bleeding, she reports two previous scanty episodes of painless vaginal bleeding, but feels that this episode has been much more severe. Obstetric examination finds a cephalic presentation with high presenting part. The uterus is non-tender. The cervical os is closed and the cervix appears normal. A. Ectopic pregnancy B. Threatened miscarriage C. Placental abruption D. Placenta praevia E. Molar pregnancyBLEEDING IN PREGNANCY MCQ 3 A 19-year-old woman presents with a two day history of central lower abdominal pain and one day history of vaginal bleeding. Her last period was 8 weeks ago. On examination her cervix is tender to touch. A. Ectopic pregnancy B. Threatened miscarriage C. Placental abruption D. Placenta praevia E. Molar pregnancyBLEEDING IN PREGNANCY MCQ 3 A 19-year-old woman presents with a two day history of central lower abdominal pain and one day history of vaginal bleeding. Her last period was 8 weeks ago. On examination her cervix is tender to touch. A. Ectopic pregnancy B. Threatened miscarriage C. Placental abruption D. Placenta praevia E. Molar pregnancyBLEEDING IN PREGNANCY MCQ 4 You are called to see a 25-year-old 10 week pregnant lady in the Emergency Department complaining of abdominal pain and heavy vaginal bleeding. Her observations are normal and she is afebrile, on ultrasound a fetal heart rate is still present and the uterus is the size expected. On examination her cervical os is closed. A. Ectopic pregnancy B. Threatened miscarriage C. Placental abruption D. Placenta praevia E. Molar pregnancyBLEEDING IN PREGNANCY MCQ 4 You are called to see a 25-year-old 10 week pregnant lady in the Emergency Department complaining of abdominal pain and heavy vaginal bleeding. Her observations are normal and she is afebrile, on ultrasound a fetal heart rate is still present and the uterus is the size expected. On examination her cervical os is closed. A. Ectopic pregnancy B. Threatened miscarriage C. Placental abruption D. Placenta praevia E. Molar pregnancyBLEEDING <24/40. DIFFERENTIALS? q Ectopic pregnancy q Miscarriage q Molar Pregnancy q Other Gynae causes: infection, cervical polyp, cervical ectropion ECTOPIC PREGNANCY Embryo implants outside uterine cavity (ampulla most common site) Risk factors: ­ Previous ectopics ­ Damage to tubes: PID/STIs, previous surgery ­ IUS/Copper IUD Always do a pregnancy test in a woman of child bearing age presenting to the ED!ECTOPIC PREGNANCY Symptoms of a ruptured ectopic: ­(<25%)ry: Shoulder tip pain, syncopal episodes ­Peritoniticn: Haemodynamically unstable, ­ Imaging: Fluid in Pouch of Douglas on USS Anti-D if surgical management and patient is Rhesus -ve as ectopic is a sensitising event! MANAGEMENT OPTIONS Expectant (Wait & Watch - Medical (Single dose of Surgical (Lap Monitor over 48 hours and Methotrexate - patient follow salpingotomy/salpingectomy) recheck bHCG) up needed!) Size <35 mm Size > 35 mm Unruptured Asymptomatic No significant pain Symptomatic No fetal heart beat Visible fetal heart beat Serum BHCG <1000 Serum BHCG <1500 Serum BHCG >5000MISCARRIAGE •Definition: Spontaneous loss of pregnancy before 24 weeks, Recurrent miscarriage: Loss of 3 or more consecutive pregnancies (affects 1% of couples) •Majority of miscarriages occur before 12 weeks •Rate increases with maternal age •Types of miscarriage (table in next slide) •Causes: Isolated chromosomal abnormalities account for >60% of sporadic miscarriages Counsel woman that exercise, intercourse, stress and emotional trauma DO NOT CAUSE MISCARRIAGES TYPES OF MISCARRIAGE Type of miscarriage Cervical Os Description Threatened Closed Viablefetus,uterusexpectedsizefordates,25%goontomiscarry Inevitable Open Heavierbleeding,fetusmaystillbealive,miscarriageabouttooccur Incomplete Open Somefetalpartshavepassed Complete Closed Allfetaltissuehaspassed,bleedingalmoststoppedanduterusnolongerenlarged Missed Closed FetusdiedinuteroanddiagnosedatUSS IX & MX OF MISCARRIAGE Investigations: Management: •USS–canberepeatedaweeklaterif womanis •When do we admit: any suspicion of ectopic stable(sometimesdifficulttodifferentialnonviable pregnancy + symptomatic, septic miscarriage, heavy andearlypregnancy) bleeding •Resuscitation •Bloods–FBC,Rhstatusif unknown,serumHCG •Removal of products from the os in cases of cervical levels shock (pain, bleeding + vasovagal shock) •Septic: septic screen, IV Abx •Anti-D if Rhesus –ve and treated surgically or if >12 weeks and heavy bleeding +/- medical mxMX OPTIONS CONTINUED Extra points: •Repeat urine pregnancy test after 3 weeks •Indications for surgical management: woman’s choice, heavy bleeding, signs of infection DRUGS FOR MISCARRIAGE, ECTOPIC & TERMINATION Miscarriage Misoprostol Termination (Two for Termination) Misoprostol - causes uterine contractions and expels pregnancy tissue Ectopic MethotrexateMOLAR PREGNANCY How does it present? - Common: Irregular vaginal bleeding, USS evidence - Less common: Hyperemesis, Large for date uterus, hyperthyroidism, early onset pre- eclampsiaBLEEDING >24 WEEKS, DIFFERENTIALS? q Placenta praevia q Placental abruption qLess common: Vasa praevia, Uterine rupture PLACENTA PRAEVIA What is it? Placenta implants in the lower segment of the uterus, Risk factors: previous , high parity and age, twins, previous CS How does it present? Incidental finding on USS, painless vaginal bleeding , abnormal lie/breech presentation What are the complications? Haemorrhage, Placenta Accreta Never perform VE in woman with APH unless PP excluded on scan How do we manage it? Rescan at 32 weeks, Admit if any bleeding, Steroids if <34 weeks, Elective CS at 39 weeksPLACENTAL ABRUPTION What is it? All or part of the placenta separates before delivery of the fetus, Risk factors: IUGR, Pre-eclampsia, HTN, Maternal smoking, previous abruption How does it present? Constant pain +/- bleeding, maternal collapse, fetal distress on CTG, woody hard/tender uterus, complications: poor UO, renal failure How do we manage it? Admit and resuscitate if severe abruption, deliver ASAP if fetal distressPLACENTA PRAEVIA VS ABRUPTION Placental Abruption Placenta Praevia Shock > External blood loss Shock = External blood loss Often severe pain, constant with Pain uncommon, occasional contractions exacerbations Bleeding: may be absent/dark Red and profuse Previous smaller APHs Tender +/- Hard uterus Rare to have tender uterus Fetal lie normal and engaged Abnormal lie + High head Fetal distress FHR normalLABOUR STAGES OF LABOUR STAGE 1: STAGE 2: • From full dilatation (10 cm) • Uterus contracts every 2-3 minutes to delivery of fetus • Passive: in the absence of • Latent phase: cervical pushing effacement + dilatation up to 3-4 cm • Active second stage: when • Active phase: 4 cm head reaches the pelvic floor onwards STAGE 3: •Progress: 2 cm every 4 hours • Until delivery of placentaLABOUR: USEFUL DIAGRAMSFETAL MONITORING: NICE GUIDELINES ESTABLISHED 1 STAGE • Immediately after a palpated contraction for at least 1 minute • Repeated every 15 minutes • Record accelerations and decelerations if heard • Palpate maternal pulse hourly SECOND STAGE • Immediately after a palpated contraction for at least 1 minute • Repeated every 5 minutes • Palpate maternal pulse simultaneouslyFETAL MONITORING: CARDIOTOCOGRAPHCTG INTERPRETATIONLABOUR MCQ 1 28 year old woman who is 18 weeks pregnant attends ED with a history of clear vaginal loss. She has a past medical history of large cone biopsy of the cervix and is allergic to penicillin. On examination, it is apparent that her membranes have ruptured. What is the most appropriate initial management? A. Discharge, USS scan the next day B. Offer her a termination as it is not possible for this pregnancy to continue C. Admit, infection markers, ultrasound and steroids D. Ultrasound, Infection markers, Observation E. Discharge and explain that she will probably miscarry at homeLABOUR MCQ 1 28 year old woman who is 18 weeks pregnant attends ED with a history of clear vaginal loss. She has a past medical history of large cone biopsy of the cervix and is allergic to penicillin. On examination, it is apparent that her membranes have ruptured. What is the most appropriate initial management? A. Discharge, USS scan the next day B. Offer her a termination as it is not possible for this pregnancy to continue C. Admit, infection markers, ultrasound and steroids D. Ultrasound, Infection markers, Observation E. Discharge and explain that she will probably miscarry at home PRETERM LABOUR What causes it? Risk of prematurity • Infection • Respiratory distress syndrome • Multiple pregnancy •NEC • APH •Neonatal jaundice • IUGR •Failure to thrive • Polyhydramnios •Cerebral palsy •can increase risk on the cervix PRETERM PRELABOUR RUPTURE OF MEMBRANES What is it? Defined as rupture of membranes between 24 and 37 weeks in the absence of uterine activity (labour) Why is it a problem? Risk of infection! + Risk of prematurity in the neonate How do we investigate? •Bloods – FBC, CRP •Confirm rupture of membranes on speculum, or fetal fibronectin (predicts risk of premature birth) How do we treat it? •Erythromycin for 10 days •Consider steroidsLABOUR MCQ 2 34 year old, P0, admitted for induction of labour at 42 weeks. She has received propess followed by 5 mg of PGE and has had an artifical rupture of membranes. Her cervix was 5 cm dilated on the previous examination and 4 hours later she is still 5 cm dilated. She is contracting 2 times every 10 minutes and has an epidural in situ. What is the most appropriate plan? A. Re-examine in 4 hours provided baby is not distressed B. Discuss the situation with the patient and offer her a caesarean section. C. Start at oxytocin infusion and intermittent monitoring and reassess in 2 hours D. Start at oxytocin infusion and commence continuous monitoringLABOUR MCQ 2 34 year old, P0, admitted for induction of labour at 42 weeks. She has received propess followed by 5 mg of PGE and has had an artifical rupture of membranes. Her cervix was 5 cm dilated on the previous examination and 4 hours later she is still 5 cm dilated. She is contracting 2 times every 10 minutes and has an epidural in situ. What is the most appropriate plan? A. Re-examine in 4 hours provided baby is not distressed B. Discuss the situation with the patient and offer her a caesarean section. C. Start at oxytocin infusion and intermittent monitoring and reassess in 2 hours D. Start at oxytocin infusion and commence continuous monitoring INDUCTION OF LABOUR • Indications – why do we induce labour? •Risk of continuing with a pregnancy > risk of delivery for mother/fetus •Obstetric Indications: IUGR (Placental insufficiency), Prolonged pregnancy, Non-reassuring CTG, severe pre- eclampsia, Obstetric Cholestasis •Medical reasons: GDM (on insulin/poorly controlled) •Bishop’s score: to assess favourability for induction (>8 = favourable cervix) •How do we do it? •Membrane sweep (offered to women if >40 weeks, 41 if multiparous) •Prostaglandins --> cause uterine contractions (Propess pessary + Prostin gel) •Oxytocin infusion •Amniotomy – artifical rupture of membranes using an amnihookBISHOP’S SCOREINDUCTION OF LABOUR: THINGS TO CONSIDER •Need for CTG monitoring and monitoring of uterine contractions •Assess Bishop’s score before starting Induction •Check for umbilical cord during VE examination (you want to rule out a cord prolapse) •Check previous scans for low lying placenta •Women informed that IOL likely to be more painful than spontaneous labour - offered pain relief (e.g. epidural) •Need to assess progress by VE – 24 hours after pessary or 6 hours after the gel. •Complications: • Uterine hyperstimulation: tocolysis, reducing oxytocin infusion rate • Uterine rupture • Failure of induction: repeat induction, offer CSCOMPLICATIONS DURING DELIVERY COMPLICATIONS DURING DELIVERY MCQ 1 Which of the following are NOT a risk factors for a breech presentation? A. Multiple pregnancy B. Previous caesarean section C. Polyhydramnios D. Placenta praevia E. Uterine malformations COMPLICATIONS DURING DELIVERY MCQ 1 Which of the following are NOT a risk factors for a breech presentation? A. Multiple pregnancy B. Previous caesarean section C. Polyhydramnios D. Placenta praevia E. Uterine malformations BREECH PRESENTATION What is it? •When the buttocks, foot or feet are presenting instead of the head in a longitudinal lie. •Is normal in preterm pregnancy <37 weeks! What are some of the Risk factors? •Uterine: Multiparity, Malformations (septate uterus), Fibroids, Placenta Praevia •Fetal: Prematurity, Macrosomia, Polyhydramnios, Abnormality How do we manage this? •ECV at 37 weeks (50% success rate) (36 for nulliparous) •If failed, elective C section around 39 weeks •Vaginal breech deliveryCOMPLICATIONS DURING DELIVERY MCQ 2 You are the junior doctor on the labour ward, and are called by a midwife to a delivery in which the baby's head has been delivered, but the shoulders will not deliver with normal downward traction. Which of these is your first step in management of this condition? • Caesarean section • Symphisiotomy • Episiotomy • Ask the mother to hyperflex their legs and apply suprapubic pressure • Wood's screw manouvereCOMPLICATIONS DURING DELIVERY MCQ 2 You are the junior doctor on the labour ward, and are called by a midwife to a delivery in which the baby's head has been delivered, but the shoulders will not deliver with normal downward traction. Which of these is your first step in management of this condition? • Caesarean section • Symphisiotomy • Episiotomy • Ask the mother to hyperflex their legs and apply suprapubic pressure • Wood's screw manouvereSHOULDER DYSTOCIA • Anterior shoulder becomes impacted behind the maternal pubic symphysis • Biggest risk factor is MACROSOMIA, particularly in woman with GDM • Maternal complications: • PPH th • 3rd/4 degree tears • Fetal complications: • Brachial plexus palsy • Fracture: clavicle, humerus • Fetal hypoxiaMX OF SHOULDER DYSTOCIA • CALL FOR HELP! • Ask the mother to stop pushing • Consider episiotomy? – can make manoeuvres easier • Mc Robert’s Manoeuvre: • Knees to chest position • Widens pelvic outlet • Success rate of 90% (even higher when combined with suprapubic pressure) COMPLICATIONS DURING DELIVERY MCQ 3 A 30-year-old woman who is 41 weeks pregnant is being induced in the labour ward. She has an artificial rupture of membranes, but the midwife notices that the umbilical cord is visibly protruding from the vagina. She is brought for an emergency caesarean section. What is the correct position for her to be in while being prepared for surgery? • Flat on her back • McRobert's position • On her back with head lowered and lower half of bed raised • On her knees and elbows • Standing COMPLICATIONS DURING DELIVERY MCQ 3 A 30-year-old woman who is 41 weeks pregnant is being induced in the labour ward. She has an artificial rupture of membranes, but the midwife notices that the umbilical cord is visibly protruding from the vagina. She is brought for an emergency caesarean section. What is the correct position for her to be in while being prepared for surgery? • Flat on her back • McRobert's position • On her back with head lowered and lower half of bed raised • On her knees and elbows • Standing CORD PROLAPSE What is it? The umbilical cord descends through the cervix, on or before the presenting part Why is this a problem? •High mortality rate – linked to the risk factors •Fetal hypoxia via: Occlusion (cord compression) + Arterial vasospasm (exposure to cold atmosphere) What are the risk factors? • Breech presentation • Unstable lie: in >37 weeks, consider inpatient admission until delivery due to risk of cord prolapse • ARM – particularly when presenting part is high in pelvis • Polyhydramnios • Prematurity MANAGEMENT OF CORD PROLAPSE • Consider this: Pathological CTG/ non-reassurng FHR trace and absent membranes • Confirmed: External inspection or VE • Fetal heart rate patterns: Decelerations or more obvious fetal bradycardia (strongly associated with prolapse due to occlusion) • CALL FOR HELP – THIS IS AN EMERGENCY! •Avoid handling the cord – to reduce vasospasm •Manually elevate the presenting part off the cord during VE •Positions: Left lateral or Knee to chest – relieves pressure off the cord •Consider tocolysis •Delivery usually via Emergency C SectionCORD PROLAPSE: DIAGRAMSCOMPLICATIONS DURING DELIVERY MCQ 4 A 36-year-old nulliparous woman is admitted in labour at 37 weeks gestation. On examination, the cervix is fully dilated, the head is direct Occipito-Anterior, the foetal station is at +1 and the head is 0/5 ths palpable per abdomen. The cardiotocogram shows late decelerations and a foetal heart rate of 100 beats/min which continue for >5 minutes. How should this situation be managed? • Caesarean section • Instrumental delivery • Continue pushing • Vaginal prostaglandin (PGE2) • Oxytocin infusionCOMPLICATIONS DURING DELIVERY MCQ 4 A 36-year-old nulliparous woman is admitted in labour at 37 weeks gestation. On examination, the cervix is fully dilated, the head is direct Occipito-Anterior, the foetal station is at +1 and the head is 0/5 ths palpable per abdomen. The cardiotocogram shows late decelerations and a foetal heart rate of 100 beats/min which continue for >5 minutes. How should this situation be managed? • Caesarean section • Instrumental delivery • Continue pushing • Vaginal prostaglandin (PGE2) • Oxytocin infusionINSTRUMENTAL DELIVERIES MATERNAL INDICATIONS: • Prolonged second stage: usually allow 2 hours of active pushing in nulliparous and 1 hour in multi • Maternal exhaustion • Maternal medical conditions: severe HTN, intracranial pathology FETAL INDICATIONS: • Suspected fetal compromise in the second stage • CTG • Fetal blood samplingINSTRUMENTAL DELIVERIES - KIWI • 2 main instruments: Kiwi/Ventouse + Forceps • Forceps have lower fetal complications and greater maternal complications • 3 contractions and pulls – if no reasonable progess then attempt abandoned • Kiwi: • Hand held disposable ventouse • Can be used for all fetal positions and rotational • Maternal risks: lower pain and perineal injury • Fetal risks: higher cephalhaematoma, higher retineal haemorrhageINSTRUMENTAL DELIVERIES - FORCEPS • Types: • Non-rotational: used for OA presentation • Wrigley’s – at C Section • Kielland’s for rotational deliveries • Higher rate of 3 and 4 degree tears with forceps – need to protect perineum when inserting the bladesCOMPLICATIONS DURING DELIVERY MCQ 5 29 year old multiparous woman in established labour contracting regularly. She is 4 cm dilated and had been having regular painful contractions for 6 hours before they stopped abruptly, heralded by sudent onset severe continuous lower abdominal pain. Fetal heart trace is difficult to identify and tocometer does not register a signal. What is the most appropriate management? A. Fetal assessment with formal ultrasound scan B. FBS C. Immediate trial of delivery in hteatre with resuscitation facilities on standby D. Immediate Caesarean section E. Expedite delivery with synthetic oxytocin infusionCOMPLICATIONS DURING DELIVERY MCQ 5 29 year old multiparous woman in established labour contracting regularly. She is 4 cm dilated and had been having regular painful contractions for 6 hours before they stopped abruptly, heralded by sudent onset severe continuous lower abdominal pain. Fetal heart trace is difficult to identify and tocometer does not register a signal. What is the most appropriate management? A. Fetal assessment with formal ultrasound scan B. FBS C. Immediate trial of delivery in hteatre with resuscitation facilities on standby D. Immediate Caesarean section E. Expedite delivery with synthetic oxytocin infusion UTERINE RUPTURE RISK FACTORS – anything WHAT ARE THE SIGNS? • Full thickness tear of the uterine muscle that makes the uterus weaker • Sudden + Severe abdo • Typically occurs during labour pain, persists between • Rare but significant maternal and fetal risks • Previous C Section contractions • Myomectomy •Shoulder tip pain • Induction of labour •Vaginal bleeding • Multiple pregnancy • O/E: regression of the • Multiparity presenting part, scar tenderness, palpable fetal parts MANAGEMENT: • Obs: hypovolaemic • AtoE approach • EMCS shock, tachycardia • Fetal monitoring: distressCOMPLICATIONS DURING DELIVERY MCQ 5 A 36-year-old woman with a background of pre-eclampsia suffers from a major postpartum haemorrhage after delivering twins. The obstetric consultant examines her and suspects uterine atony to be the cause. The protocol for major PPH is initiated. Bimanual uterine compression fails to control the haemorrhage. Which of the following drugs should be avoided in this case to manage her PPH? A. Carboprost B. Misoprostol C. Oxytocin D. Ergometrine PRIMARY PPH How do we define it? Blood loss of > 500 mls after SVD or > 1L after C Section Risk factors for uterine atony: • Maternal: High BMI, age > 40, Asian ethnicity • Uterine over-distension: polyhydramnios, multiple pregnancy, macrosomia • Labour: Induction, Prolonged • Placental problems: Praevia, Abruption, Previous PPHMANAGEMENT OF PPHAGEMENT OF PPH UTERINE ATONY: • Bimanual compression to stimulate uterine contraction • Drugs: Oxytocin, Ergometrine, Carboprost, Misoprostol • Surgical measures: Intruterine balloon tamponade, Haemostatic suture, Hysterectomy TRAUMA • Primary repair of laceration • If rupture: laparotomy + repair/hysterectomyMANAGEMENT OF PPH TISSUE: • IV Oxytocin • Manual removal of placenta • Prophylactic Abx in theatre THROMBIN: • Correct coagulation abnormalities with blood products • Discuss with haematologyCONDITIONS IN PREGNANCYCONDITIONS IN PREGNANCY: MCQ 1 A 32-year-old pregnant woman of South Asian origin is 24 weeks into her second pregnancy. She has had one natural delivery at 39 weeks to a healthy child, and no other level is 7.2 mmol/L.. She has a family history of Type 2 Diabetes. Her fasting glucose What is the most appropriate initial management given her fasting glucose level? • Advice on diet and exercise • Advice on diet and exercise plus daily blood glucose monitoring • Gliclazide • Insulin • MetforminCONDITIONS IN PREGNANCY: MCQ 1 A 32-year-old pregnant woman of South Asian origin is 24 weeks into her second pregnancy. She has had one natural delivery at 39 weeks to a healthy child, and no other level is 7.2 mmol/L.. She has a family history of Type 2 Diabetes. Her fasting glucose What is the most appropriate initial management given her fasting glucose level? • Advice on diet and exercise • Advice on diet and exercise plus daily blood glucose monitoring • Gliclazide • Insulin • Metformin GESTATIONAL DIABETES (GDM) GDM risk factors + screening questions: • BMI > 30 • Family history of diabetes (1t degree relative) • Ethnicity – South Asian, Chinese, Screening & Diagnosis of GDM African-Caribbean, Middle East • Previous macrosomic baby (> 4.5 • 75 g 2 hour OGTT at 24-28 weeks kg) • Fasting plasma glucose level:>/= 5.6 • Previous GDM • 2 hour OGTT: >/= 7.8 MANAGEMENT OF GDM Management of GDM: 1. Offer the woman an appointment in the diabetes antenatal clinic within 1 week 2. Counselling on complications of diabetes, self-monitoring of glucose and importance of glycaemic control 3. Diet control, Metformin, Insulin Fasting plasma glucose Management <7 at diagnosis Diet and exercise trial for 1-2 weeks Metformin Insulin >7 at diagnosis Insulin +/- Metformin + Diet and Exercise 6.0– 6.9 + complications such as macrosomia and Insulin +/- Metformin + Diet and Exercise polyhydramniosCOMPLICATIONS OF GDM MATERNAL COMPLICATIONS FETAL COMPLICATIONS • Increased risk of pre-eclampsia • Increased risk of infections • Increased risk of malformations X3 • Macrosomia • Higher rates of Induction of labour & • Shoulder dystocia Caesarean section • Polyhydramnios • Higher rates of miscarriage • Preterm birth • Stillbirth • Hypoglycaemia after birth • Increased risk of diabetes and obesity in later life CARE OF WOMEN WITH GDM ANTENATAL CARE DELIVERY/LABOUR • Appointments with diabetic clinic every 1-2 weeks • Women with GDM advised to give birth by • Scans: 40+6 weeks • Detailed anomaly scan at 18-20 weeks • Offer elective birth by induction or CS if with 4 chamber heart view at the they have not given birth by this time anomaly is sufficient • If maternal or fetal complications – • Growth scans every 4 weeks from 28 consider elective birth before 40+6 weeks onwards – Monitor AC as most • Corticosteroids if preterm (why? what is the sensitive marker of macrosomia risk?) • Self-monitoring: • During labour: continuous CTG, consider • Fasting (Target: 5.3) and 1-hour post- sliding scale insulin, requirements decrease meal (Target: 7.8) levels daily post delivery POSTPARTUM CARE • Discontinue blood glucose lowering therapy immediately after birth • Counsel about risk of GDM in future pregnancies, moderate risk of Type 2 DM • Offer lifestyle advice • GP to check fasting plasma glucose at 6 week postnatal check/ HbA1C if after 13 weeks • If fasting glucose between 6.0-6.9 – high risk of developing Type 2 diabetes • If fasting glucose >7 then likely to have Type 2 DM WOMEN WITH PRE-EXISTING DIABETES ANTENATAL CARE & DELIVERY • Hypoglycaemia counselling PRE-CONCEPTION COUNSELLING • Exclude ketoacidosis if unwell • Assess renal function and retinal screen •Aim for a HbA1C of </= 48 • Type 1 or Type 2 DM with no complications: Elective birth (IOL/CS) mmol/mol (6.5%) between 37 and 38+6 weeks •High dose folic acid 5 mg daily • Before 37 weeks if any complications preconception •Arrange dietician review •Stop oral hypoglycaemics except POSTPARTUM metformin, also stop statins and • Return to pre-pregnancy regimen – reduce insulin dose immediately ACEi/ARBs after birth • Advise to snack before and after feeds to reduce risk of hypos with •Retinopathy and nephropathy screen breastfeeding • Insulin and metformin are safe to use in breastfeedingCONDITIONS IN PREGNANCY: MCQ 2CONDITIONS IN PREGNANCY: MCQ 2 Answer: B CONDITIONS IN PREGNANCY: MCQ 3 A 26-year-old woman was admitted at 34 weeks gestation with preterm labour. On examination she has a blood pressure of 175/105 mmHg. Urinalysis reveals 3+ proteinuria. She is commenced on magnesium sulphate and labetalol. She is now complaining of reduced foetal movements. A cardiotocogram shows late decelerations and a foetal heart rate of 90 beats/minute. What should be the next step in the management? • Give further Magnesium Sulphate • Elective caesarian section • Emergency caesarian section • Foetal scalp pH testing • Induce labour CONDITIONS IN PREGNANCY: MCQ 3 A 26-year-old woman was admitted at 34 weeks gestation with preterm labour. On examination she has a blood pressure of 175/105 mmHg. Urinalysis reveals 3+ proteinuria. She is commenced on magnesium sulphate and labetalol. She is now complaining of reduced foetal movements. A cardiotocogram shows late decelerations and a foetal heart rate of 90 beats/minute. What should be the next step in the management? • Give further Magnesium Sulphate • Elective caesarian section • Emergency caesarian section • Foetal scalp pH testing • Induce labour PRE-ECLAMPSIA What is the pathophysiology of • Hypertension (>140/90) and proteinuria or if pre-eclampsia? there has been (also consider booking BP) • Develops after 20 weeks and resolves within 6 weeks of delivery RISK FACTORS HIGH RISK MODERATE RISK If 1 high or 2 moderate: • Previous severe or early st aspirin 150 mg OD from onset pre-eclampsia • 1 pregnancy 12 weeks until delivery. • Chronic hypertension or • >40 years MUST be started < 16 hypertension in previous • Pregnancy interval weeks to be effective pregnancy of >10 years • CKD • BMI >30 (aspirin is thought to aid • Diabetes • FHx of pre- effective trophoblastic • Autoimmune disease (SLE, eclampsia invasion which happens APS, Thrombophilia) • Multiple pregnancy in the first trimester) CLINICAL PRESENTATION SYMPTOMS SIGNS • Might be absent in mild pre- eclampsia • Hypertension + • To ask in every consultation: proteinuria • Headache • Epigastric tenderness • Flashing lights/ Blurring • Epigastric or RUQ pain/ • Brisk reflexes severe pain just below • Confusion, fits ribs • Placental abruption • IUGR (estimated fetal • Nausea and vomiting weight <10 centile) • Sudden swelling of face, fingers or lower limbs • Stillbirth INVESTIGATION AND ADMISSION How do we investigate pre- eclampsia? What would you When do we admit someone to hospital? find in these blood test results? • Sustained systolic blood pressure >/= • FBC 160 mmHg • Clotting • Concerning biochemical Ix • LFTs • Signs of pulmonary oedema • Urine PCR >30 • Signs of impending eclampsia • Serum uric acid • Suspected fetal compromise • Signs of severe pre-eclampsia TREATMENT How do we treat pre- eclampsia? Fetal monitoring in pre-eclampsia • 1 Line: Labetalol • At diagnosis: USS for fetal growth and amniotic fluid • 2 line: Nifedipine + Doppler rd • Repeat this every 2 weeks OR earlier if any of the • 3 line: Methyldopa following symptoms: • Change in fetal movements • Target BP: 135/85 or less • Vaginal bleeding • BP monitoring at least every 48 • Abdo pain • Deterioration in maternal condition hours • Blood tests twice a week DECISIONSAROUNDDELIVERY DELIVERY & TIMING OF BIRTH • If no complications deliver women after 37 weeks • When would you consider delivering women before 37 weeks? • Deterioration in bloodsng BP despite 3 or more anti-hypertensives • Neuro symptoms including eclampsia • Abruption • Doppler: reversed end diastolic flow or abnormal CTG • Considerations for preterm delivery: • Discuss with neonates • IV Mag sulphate if before 30 weeks • Corticosteroids between 24 and 34+6 weeks DELIVERY&POSTNATALCARE INTRAPARTUM POSTPARTUM • Regular monitoring of blood pressure: 1 • BP monitoring hourly in HTN, every 15-30 minutes in severe • Repeat PET bloods hypertension • Consider reducing if BP falls below • Continue antihypertensives 140/90 • Consider operative or assisted delivery in • If discharged on treatment, GP review in second stage for uncontrolled hypertension 2 weeks or 6 weeks routine review if no meds ECLAMPSIA ABCDE - continuously monitor oxygen saturation and BP Magnesium sulphate IV bolus and then infusion. OTHER CAUSES OF SEIZURES: Repeated seizures treated with diazepam • Cerebral venous sinus thrombosis Regular observations + catheter to monitor urine output • Intracranial mass • Stroke Bloods: FBC, U&E, LFT, creatinine, clotting • Hypoglycaemia • Hyponatraemia Monitor for signs of MgSO4 toxicity: RR<12, tendon relfex loss, urine output <20 • Infection ml/h, ANTIDOTE? CTG for fetal heart rate monitoring Deliver once mother is stableCONDITIONS IN PREGNANCY: MCQ 4 A woman complains of severe itching at 34 weeks gestation. The itching started 2 weeks previously and has been preventing her from sleeping. She is itchy all over her body, especially in her hands and feet. She has not noticed any rashes. Her mother reports similar symptoms when she was pregnant with her 2nd child. She is otherwise well. What is the most appropriate action? A. Dermatology referral B. Treat with topical steroids C. Check uric acid levels E. ChCheck bile acidson testsCONDITIONS IN PREGNANCY: MCQ 4 A woman complains of severe itching at 34 weeks gestation. The itching started 2 weeks previously and has been preventing her from sleeping. She is itchy all over her body, especially in her hands and feet. She has not noticed any rashes. Her mother reports similar symptoms when she was pregnant with her 2nd child. She is otherwise well. What is the most appropriate action? A. Dermatology referral B. Treat with topical steroids C. Check uric acid levels E. ChCheck bile acidson testsDerm differentials Obstetric Cholestasis Features of the itch: ● 3rd trimester ● Palms and soles ● Worse at night ● Severe with excoriations Other features: jaundice, malaise, anorexia, dark urine + pale stools, steatorrhea Ix: Raised bile acids +/- Abnormal LFTs Mx: ● Repeat LFTs every 1-2 weeks ● Consider Ursodeoxycholic acid for symptomatic relief ● Induction of labour depending on bile acid levels (if >100 then IOL at 35-36 weeks)CONDITIONS IN PREGNANCY: MCQ 5 A 19-year-old woman presents to your surgery 14 weeks into her second pregnancy. Her pregnancy has been progressing normally so far, including a normal dating scan at 10 weeks. She visited 24 hours ago due to excessive nausea and vomiting and was started on oral cyclizine 50mg TDS. However, she is still unable to tolerate any oral intake, including fluids. Her urine dip is positive for ketones. What is the most appropriate next step? A - Repeat ultrasound scan B - Advise bed rest and arrange for district nurses to administer IM anti-emetics C - Switch anti-emetic to metoclopramide D - Reassure as most women experience a settling of nausea and vomiting by the 16th week of pregnancy E - Arrange admission to hospitalCONDITIONS IN PREGNANCY: MCQ 5 A 19-year-old woman presents to your surgery 14 weeks into her second pregnancy. Her pregnancy has been progressing normally so far, including a normal dating scan at 10 weeks. She visited 24 hours ago due to excessive nausea and vomiting and was started on oral cyclizine 50mg TDS. However, she is still unable to tolerate any oral intake, including fluids. Her urine dip is positive for ketones. What is the most appropriate next step? A - Repeat ultrasound scan B - Advise bed rest and arrange for district nurses to administer IM anti-emetics C - Switch anti-emetic to metoclopramide D - Reassure as most women experience a settling of nausea and vomiting by the 16th week of pregnancy E - Arrange admission to hospitalHYPEREMESIS GRAVIDARUM Morning sickness → Nausea and Vomiting When to consider admission? of Pregnancy → Hyperemesis • Unable to keep fluids down/failure of oral anti- Gravidarum emetics Pathophysiology: Rising levels of HCG triggers CTZ in the brainstem (multiple • Ketonuria, Weight loss >5% pre-pregnancy pregnancies, trophoblastic disease - get a • Co-morbidity - diabetes, UTI scan) Check TFTs - associated with hyperthyroidism (BHCG has TSH like activity) Occurs in 1st trimester and subsides by 16 weeks MANAGEMENT Other points to consider: • Normal saline 0.9% with added KCL • Daily monitoring of electrolytes • Combinations of drugs should be used FIRST LINE • Thiamine supplementation to all women ü Xonvea (Doxylamine and Pyridoxine) admitted with NVP ü Cyclizine ü Prochlorperazine • Serial scans if continued symptoms into later second and third trimester ü Promethazine • All therapeutic measures should have been offered before considering termination of SECOND LINE pregnancy ü Metoclopramide ü Ondansetron THIRD LINE ü CorticosteroidsUseful Resources