xss28 - obstetrics

SYMPTOM SUMMARIES

OBSTETRICS

DARWIN’S NOTEBOOK

TABLE OF CONTENTS

BLEEDING / PAIN IN EARLY PREGNANCY 1

BLEEDING IN 2ND & 3RD TRIMESTERS 5

ABDOMINAL PAIN IN 2ND & 3RD TRIMESTERS 8

LARGE- OR SMALL-FOR-DATES 13

HYPERTENSION IN PREGNANCY 17

FAILURE TO PROGRESS IN LABOUR 20

ABNORMAL CTG IN LABOUR 24

POSTPARTUM HAEMORRHAGE 29

STILLBIRTH 33

MATERNAL COLLAPSE 36

OBSTETRICS – BLEEDING / PAIN IN EARLY PREGNANCY

DARWIN’S NOTEBOOK 1

Introduction

• The history, examination & investigations must be aimed at distinguishing an ectopic pregnancy from a miscarriage

• Women with bleeding or pain in early pregnancy will be anxious ® so sensitive explanations are

important, particularly when the diagnosis is uncertain and further investigations are necessary

History

LAST MENSTRUAL PERIOD

• The first day of the last menstrual period (LMP) will allow you to calculate the gestation ® this

becomes important when interpreting early pregnancy scans o NB: While an empty uterus at 7 weeks might indicate an ectopic pregnancy, a small gestation

sac with no foetal pole is common at 5 weeks

• However, it is important to establish whether the woman is sure of her dates and whether her cycle is

regular ® if not, the estimated gestation may be wrong

• If she conceived while taking the pill ® the last period cannot be relied upon to predict the gestation, as

it was a hormonally induced withdrawal bleed

BLEEDING

• Some women might not realise that there is a problem with their pregnancy until they have a scan

• Miscarriage does not always start with heavy bleeding, and the loss seen with ectopic pregnancy is

variable ® so the amount of bleeding CANNOT be used to predict the problem (unless the woman has

seen products of conception mixed with the bleeding, in which case she is having an inevitable

miscarriage)

• Products may be described as ‘pieces of tissue’ ® heavy blood flow will form clots that can be

described as being ‘like liver’

• The woman might connect the onset of bleeding to an event such as intercourse or exercise ® it is

possible for the cervix (which is more friable in pregnancy) to bleed postcoitally, but actual miscarriage

is not provoked by intercourse

• The differential diagnosis for bleeding in early pregnancy includes:

o Threatened miscarriage ® ongoing pregnancy (the cervix is closed)

o Non-viable pregnancy ® complete, incomplete, or delayed miscarriage

o Molar pregnancy

o Ectopic pregnancy

o Local cause ® e.g. cervical ectropion or carcinoma

PAIN

• Miscarriage typically causes cramping, central, lower abdominal pain ® the patient might describe it

as ‘like period pains’ or ‘like contractions’

• It may have started suddenly, or could have been preceded by days or weeks of spotting

• The pain of a tubal ectopic pregnancy may be worse on one side than the other, and centred around

the iliac fossa ® there might have been dyspareunia on that side over the previous few days and, as

a result of blood irritating the bowel, the woman might have had some diarrhoea

• If an ectopic pregnancy ruptures ® it causes pain all over the abdomen and referred shoulder-tip pain

because of blood irritating the inferior surface of the diaphragm



PAST OBSTETRIC HISTORY

• A history of miscarriage or ectopic pregnancy increases the risk of these problems recurring

PAST MEDICAL HISTORY

• This should focus on any conditions that predispose to ectopic pregnancy:

• Also remember that a woman who has a non-viable or ectopic pregnancy may need surgery ® so

attention should be paid to conditions that may affect fitness for anaesthesia

Examination

OBSERVATIONS

• The woman might be experiencing significant pain if the uterus is expelling clots of products, or if an

ectopic pregnancy has ruptured ® her pulse & BP should be measured

• Miscarriage is unlikely to cause shock due to hypovolaemia ® but, rarely, cervical shock is seen, in

which there is a vagal response to dilatation

• Haemorrhage from a ruptured ectopic pregnancy can be massive ® the pulse will be weak &

tachycardiac, the BP will be low, and the patient will look pale, sweaty & unwell and might collapse

ABDOMINAL EXAMINATION

• With miscarriage, the abdomen will be soft ® if more than 12/40, or if the uterus is fibroid, it might be

palpable above the symphysis pubis

• With ectopic pregnancy, the uterus will not be palpable abdominally:

o Before it ruptures ® there will be tenderness on the affected side, and there might be some

guarding and rebound

o Once ruptured ® the entire abdomen will be tense & tender, with guarding and rebound

CUSCO’S SPECULUM EXAMINATION

• The cervix should be visualised, and swabs taken from the endocervix and vagina

• An ectropion or, rarely, a cervical carcinoma, might be visible

o NB: An ectropion is not pathological, it is simply an extension of endocervical columnar epithelium, which bleeds easily, onto the ectocervix and is common in pregnancy due to

oestrogen ® no treatment is necessary unless infection is shown

• It might be possible to see if the os is open or closed ® but this is best determined by palpation



VAGINAL EXAMINATION

• In early pregnancy, if the woman has had a labour in the past, the external os may be open (‘multip’s os’) but the internal os should be closed

• An open internal os indicates an inevitable miscarriage ® a closed os might be seen with

miscarriage or with ectopic pregnancy

• The uterine size in weeks should be estimated

• The adnexa should be examined ® an ectopic pregnancy may cause fullness and tenderness on the

affected side

• Cervical excitation is pregnant with an ectopic pregnancy

Investigation

• Blood tests:

o FBC ® the woman is unlikely to be anaemic due to the bleeding of a threatened miscarriage,

but there might be pre-existing anaemia (which is important from an anaesthetic point of view),

and a ruptured ectopic may result in severe anaemia

o Blood group ® women who are Rhesus negative will require anti-D after an operation for

ectopic pregnancy, evacuation of retained products of conception (ERPC), or after an episode

of bleeding after 12 weeks

o Serum b-hCG ® can be helpful in diagnosing an asymptomatic ectopic pregnancy, as an

intrauterine pregnancy should be seen on transvaginal USS with levels >1500

• Ultrasound scan:

o Transvaginal scans give the best views in early pregnancy

o The uterus is examined ® looking for a gestation sac & foetal pole, and then for a foetal

heartbeat

o If the uterus is empty ® the adnexa are scanned, looking for a mass (indicating ectopic

pregnancy) o Sometimes a live ectopic is seen, where the ectopic gestation sac contains a foetus with a

heartbeat

o Free fluid (due to bleeding from the ectopic) might be seen in the pouch of Douglas

o With a miscarriage, retained products of conception may be seen § NB: Once a foetal heartbeat is seen on USS, there is a 90% chance of the pregnancy

continuing ® foetal heart activity can be seen from ~7/40 gestation

Recurrent miscarriage

• A woman who has had three or more consecutive 1st trimester miscarriages should have the same history and examination as above

• Extra investigations should also be considered:

o Karyotyping ® of both partners and of products of conception where appropriate

o USS ® to assess the uterine cavity and the ovaries

o High vaginal swab ® to screen for bacterial vaginosis

o Antiphospholipid antibodies assay ® on two occasions at least 6 weeks apart

• Cervical weakness is best diagnosed by careful history taking, where there will be a history of painless

cervical dilatation or spontaneous rupture of membranes in the 2nd trimester ® transvaginal scan of the

cervical canal can aid diagnosis, showing an open internal os and short canal



Trophoblastic disease

• Presentation can occur in several ways:

o Bleeding in early pregnancy, investigated by USS ® which reveals a molar pregnancy with a

characteristic ‘bunches of grapes’ appearance

§ NB: A partial mole pregnancy might not appear abnormal on scan

o USS for dating in early pregnancy ® routine, or ordered due to larger than expected uterus

o Exaggerated symptoms of pregnancy due to high b-hCG levels ® e.g. hyperemesis

gravidarum

o Products of conception following miscarriage and ERPC are reported by the histopathologist as

showing partial or complete mole

o Persistently raised b-hCG following ectopic pregnancy, miscarriage, or term delivery

Summary

OBSTETRICS – BLEEDING IN 2ND & 3RD TRIMESTERS


Differential diagnosis

• Antepartum haemorrhage (APH) is defined as vaginal bleeding from 24 weeks’ gestation

• The differential diagnosis of APH includes:

Source of haemorrhage Type of haemorrhage

Uterine source Placenta praevia Placental abruption Vasa praevia Circumvallate placenta

Lower genital tract source Cervical ectropion Cervical polyp Cervical carcinoma Cervicitis Vaginitis Vulval varicosities

Unknown origin

• Placenta praevia and placental abruption are associated with increased maternal and foetal morbidity & mortality

• The majority of bleeding is unexplained

• NB: Bloody mucoid vaginal loss might be the ‘show’ associated with the onset of labour

• It is important to note that perinatal mortality doubles following even minor episodes of bleeding

• Also, a patient who presents with an APH has an associated risk of postpartum haemorrhage (PPH)

History

• Important points to elicit in the history are: o Amount of bleeding

o Association with abdominal pain

o Association with mucoid discharge

• There may be an obvious trigger event ® e.g. recent sexual intercourse (causing bleeding from a

cervical lesion) or a road traffic accident (causing a placental abruption)

• The result of the patient’s last smear test is relevant to exclude a cervical cause for the bleeding

• The patient should be asked about the presence of foetal movements

• The presence or absence of constant abdominal pain is particularly important ® it will help in the

clinical differentiation between placenta praevia and placental abruption

o NB: Abruption does not have to be associated with visible bleeding ® concealed abruption

• Pain may also be caused by uterine contractions ® with an abruption, the uterine myometrium becomes

infiltrated by blood, which can initiate contractions or simply make the uterus irritable

Examination

MATERNAL WELLBEING

• Pulse & BP

• Pallor

• Abdominal palpation ® to elicit uterine tenderness and/or uterine contractions

• Speculum examination ® to exclude cervical abnormalities

• Digital examination ® if the patient appears to be in labour to assess for cervical change, but ONLY IF

PLACENTA PRAEVIA HAS BEEN EXCLUDED



FOETAL WELLBEING

• Abdominal palpation ® to assess the lie and presentation of the foetus, as well as engagement of

thee presenting part o NB: It might be difficult to palpate foetal parts in the case of an abruption

• Auscultation of the foetal heart ® to determine foetal viability

Investigation

• Blood tests: o Initial investigations include taking blood for a haemoglobin level, clotting profile, and

group-and-save

o Blood might need to be crossmatched if the bleeding is heavy ® especially with major placenta

praevia

o A Kleihauer test should be sent in the case of a suspected placental abruption ® foetal RBCs

are seen in the maternal blood

o If the mother is Rhesus negative ® she should be given anti-D immunoglobulin to prevent

haemolytic disease of the newborn in a future pregnancy (even with a minor degree of

antepartum bleeding after 12 weeks’ gestation)

• Foetal monitoring: o A cardiotocograph (CTG) should be done to confirm foetal wellbeing after 26 weeks’

gestation

o It will also assist inn monitoring uterine activity ® either established contractions or an irritable

uterus

• Ultrasound scan:

o Part of the routine 20-week anomaly scan is to check the placental site ® an USS should be

arranged if it has not already been done

o This can be performed transvaginally to check the position of the leading placental edge in

relation to the internal cervical os ® particularly if the placenta is posterior

o NB: It is important to differentiate between major and minor placenta praevia

o The scan might also reveal a retroplacental haematoma suggesting placental abruption, but

this diagnosis is normally made on clinical grounds ® a small haematoma might be missed on

scan, especially if the placenta is posterior

Management

• Management of the pregnancy depends on the amount of bleeding, the condition of the mother and foetus, and the likely cause of the bleeding

• If a cervical cause is suspected ® the patient might need to be referred for further investigation, such as

colposcopy

PLACENTA PRAEVIA

• Conservative management is appropriate if the bleeding is only mild to moderate in the 2nd trimester ®

especially in a preterm pregnancy

• If delivery is anticipated in such a case ® then IM corticosteroids should be administered to improve

foetal lung maturity



• Inpatient care is advised for women with major placenta praevia after 36 weeks ® because of the

unpredictability of the timing of labour, and the potential for heavy vaginal bleeding

• If the placenta is within 2cm of the internal os ® caesarean section is necessary

PLACENTAL ABRUPTION

• Again, with mild to moderate bleeding, expectant management is appropriate

• However, depending on the clinical scenario, immediate delivery might be necessary in the interests of

the mother and the foetus

Summary

OBSTETRICS – ABDOMINAL PAIN IN 2ND & 3RD TRIMESTERS



• The important differential diagnosis when assessing abdominal pain in pregnancy is whether the cause is obstetric or non-obstetric

• Systems that may be involved include:

History

CURRENT OBSTETRIC HISTORY

• This should include the current gestation and the parity

• The antenatal history may be relevant ® e.g. if the patient has a history of pregnancy-induced

hypertension, then she is at risk of pre-eclampsia and placental abruption

PRESENTING SYMPTOMS

• As with any history of pain, its characteristics are important:

o Nature ® continuous or intermittent

o Quality ® stabbing, burning, tightening, etc.

o Site ® generalised or specific

o Radiation ® to the pelvis or to the back

o Duration

o Exacerbating factors

• It is important to ask about other symptoms ® particularly GI and GU symptoms, such as frequency of

bowel habit, vomiting, or dysuria


• A history of pre-eclampsia or preterm labour in a previous pregnancy puts the patient at increased risk in her current pregnancy

PAST GYNAECOLOGICAL / MEDICAL / SURGICAL HISTORY

• Ultrasound scans earlier in the pregnancy may have diagnosed an ovarian cyst or uterine fibroids

• There might be a history of peptic ulcer disease or gallstones

• If the patient has previously had an appendicectomy or a cholecystectomy ® these can be excluded



Examination

GENERAL EXAMINATION

• As with any clinical examination, the general condition of the pregnant patient should be assessed, including:

o Temperature

o Pulse

o Blood pressure

o Respiratory rate

o Cardiovascular system

o Respiratory system

ABDOMINAL PALPATION

• The abdomen should be inspected for any previous operation scars

• In the presence of a gravid uterus, abdominal palpation to stablish the cause of the symptoms may not

be straightforward ® compared with examining a non-pregnant patient, the site of the tenderness might

not be typical, as the gravid uterus interferes with the usual anatomical markings (e.g. tenderness and guarding in the iliac fossa with ovarian cyst torsion, or tenderness at McBurney’s point with

appendicitis)

• The uterus should be palpated to determine: o Lie, presentation & engagement of the foetus o Presence of uterine contractions

o Generalised or specific uterine tenderness

o Presence of uterine fibroids

• NB: When examining an obstetric patient, she should be examined with left lateral tilt ® if she lies

supine, pressure on the large vessels reduces venous return to the heart and causes supine

hypotension

VAGINAL EXAMINATION

• A speculum examination is appropriate to exclude cervical causes of bleeding

• A digital examination may be indicated if the history and abdominal palpation suggest that the patient

is in labour ® in order to determine if there is cervical change

Investigation

• Appropriate investigations may include: o FBC

o Clotting studies

o Group-and-save sample

o Urea / electrolytes

o LFTs

o CRP

o Glucose

o Urinalysis / MSU / 24h urine collection for protein

o CTG

o USS of the uterus, ovaries, kidneys, liver, and gallbladder

BLOOD TESTS

• FBC / clotting studies:

o The FBC can show a reduced haemoglobin if the patient is bleeding ® e.g. in placental

abruption



o The platelet count might be low in association with pre-eclampsia or HELLP syndrome ®

this may be associated with abnormal clotting studies

o A group-and-save is essential if there is ongoing bleeding ® in case crossmatched blood is

required for transfusion

o With the non-obstetric causes of pain ® the WCC will be raised if there is an infection, e.g.

pyelonephritis or cholecystitis

• Urea / electrolytes / glucose / LFTs:

o In pre-eclampsia or HELLP syndrome ® urea, creatinine & liver transaminases can be

raised

o Serum uric acid is also high in pre-eclampsia, and in acute fatty liver ® the latter is

associated with hypoglycaemia

URINALYSIS / MIDSTREAM URINE SAMPLE

• In pre-eclampsia, there is proteinuria on dipstick, and a 24h urine collection will quantify the amount of

protein in order to determine the severity of the disease ® in some units, this is assessed by doing a

urine protein-to-creatinine ratio on a single sample

• Proteinuria may also present with a UTI ® it might be associated with microscopic haematuria,

particularly in the presence of renal calculi

CARDIOTOCOGRAPH

• Before 24/40 gestation, the foetal heart should be auscultated with a pinard or a sonicaid

• A CTG is performed after 24-26 weeks, and will help determine foetal wellbeing ® particularly in the

case of placental abruption

• The recording will also detect uterine activity ® including the presence & frequency of uterine

contractions

ULTRASOUND SCAN (UTERUS / OVARIES / KIDNEYS / LIVER / GALLBLADDER)

• Although generally a clinical diagnosis, an obstetric scan might show a retroplacental haematoma in the case of severe placental abruption

• If preterm delivery is necessary (e.g. in acute fatty liver) ® foetal wellbeing and growth should be

assessed, and the foetal weight estimated to inform the paediatricians

• For the other systems, US examination can assist diagnosis and management: o An ovarian cyst might be seen if haemorrhage, rupture or torsion of the cyst is suspected

o Renal stones or gallstones can be visualised

Management

• This depends on the cause of the pain and the gestation of the pregnancy

• With regard to obstetric causes, caesarean section or induction of labour might need to be

considered ® in severe pre-eclampsia, for example, the benefits of delivery to the mother’s health can

outweigh the risks to the foetus of preterm birth

• Placental abruption might be severe enough to compromise the foetus ® delivery should be expedited

• However, most conditions can be managed conservatively ® this includes analgesia for renal stones,

or antibiotics for pyelonephritis



• Multidisciplinary management with other specialties is important ® e.g. gastroenterology in suspected

gallstones or peptic ulcer

• Depending on the clinical findings, surgery is necessary for acute appendicitis or ovarian torsion

Summary

• Key diagnoses of abdominal pain and their clinical features:

Differential diagnosis Clinical features

Labour Intermittent pain, usually regular in frequency, associated with uterine tightenings The presenting part of the foetus is usually engaged Vaginal examination shows cervical change

Placental abruption Mild or severe pain, more commonly associated with vaginal bleeding The uterus is usually tender on palpation, and can be irritable or tense There might be symptoms and signs of pre-eclampsia

Symphysis pubis dysfunction Pain is usually low and central in the abdomen just above the symphysis pubis, which is tender on palpation Symptoms are worse with movement

Ligament pain Commonly described as sharp pain, which is bilateral and often associated with movement

Pre-eclampsia / HELLP syndrome Epigastric or right upper quadrant pain, associated with nausea & vomiting, headache, and visual disturbances On examination, there is hypertension and proteinuria

Acute fatty liver of pregnancy Epigastric or right upper quadrant pain, associated with nausea, vomiting, anorexia, and malaise

Ovarian cyst Unilateral pain, which is intermittent and may be associated with vomiting

Uterine fibroid Pain is localised and constant Fibroid is noted on palpation and is tender

Constipation Usually suggested by the history Can cause lower abdominal discomfort and bloating

Appendicitis Pain associated with nausea and vomiting Tenderness with guarding and rebound might be localised to the right iliac fossa

Gallstones / cholecystitis Right upper quadrant or epigastric pain, which may radiate to the back or the shoulder-tip Tenderness in the right hypochondrium and pyrexia with cholecystitis

Pancreatitis Epigastric pain radiating to the back, associated with nausea and vomiting Occurs most commonly in the third trimester

Peptic ulcer Epigastric pain associated with food There might be heartburn, nausea, or occasionally haematemesis

Cystitis Usually suggested by the history Pain and tenderness in the lower abdomen or suprapubically

Renal stones / renal colic / pyelonephritis Loin pain that might radiate to the abdomen and groin, possibly associated with vomiting and rigors Pyrexia is present with pyelonephritis



• An algorithm for the diagnosis of abdominal pain:

OBSTETRICS – LARGE- OR SMALL-FOR-DATES



• The growth of a pregnancy is estimated by measuring the symphysis-fundal height ® this takes into

account the size of the foetus, the liquor volume, and the maternal structures (including the uterus)

• Before deciding whether it is abnormal or not ® the dates of the LMP and the previous scan reports

should be checked to confirm the gestation of the pregnancy, and also whether it is a singleton

pregnancy

• The differential diagnoses of the large-for-dates (LFD) or small-for-dates (SFD) uterus can be considered in two categories:

o Foetal / placental o Maternal

• A foetus found to be SFD can be categorised according to its growth pattern, diagnosed with serial US scans:

o Small for gestational age (SGA) ® the foetus is small for the expected size at a certain

gestation, but continues to grow at a normal rate

o Intrauterine growth restriction (IUGR) ® the foetus is small or normal sized for the expected

size at certain gestation, but the growth slows down as the pregnancy advances

• In general: o The foetal causes of oligohydramnios are related to its ability to produce urine (and thus

liquor)

o The foetal causes of polyhydramnios are secondary to its inability to swallow liquor

History


• With respect to the LFD uterus, a patient who had gestational diabetes in a previous pregnancy is at

risk of developing the same condition again ® this disorder puts the pregnancy at risk of macrosomia

and polyhydramnios

• A previous history of a baby that was SGA or IUGR (whether in relation to pre-eclampsia or not) increases the risk of a future pregnancy being similarly affected

PAST GYNAECOLOGICAL HISTORY

• A diagnosis of uterine fibroids or an ovarian cyst, either prior to pregnancy or in early pregnancy, can cause the symphysis-fundal height to palpate as LFD


• Diabetes mellitus increases the chance of foetal macrosomia and polyhydramnios ® the abdomen

will palpate LFD, as in gestational diabetes

• Foetal infection with toxoplasmosis, cytomegalovirus, rubella, or herpes may produce

polyhydramnios ® so the mother should be asked about recent flu-like illness or rash

• Current maternal disease increases the risk of IUGR (and therefore a SFD uterus):

o Renal disease ® including renal transplantation

o Hypertension o Congenital heart disease

o Severe anaemia

o Sickle-cell disease



o SLE

o Cystic fibrosis o HIV infection

FAMILY HISTORY

• In relation to a LFD uterus, a family history of DM will put the patient at increased risk of developing

gestational diabetes in her current pregnancy

• There is also evidence that a family history of pre-eclampsia is relevant ® this disorder can be

associated with IUGR

SOCIAL HISTORY

• The ethnic group of the patient can be relevant in a SFD patient ® the growth charts used were derived

from Caucasian populations, in whom the average birthweight is greater than, for example, an Asian

population

• Smoking in pregnancy is a major cause of a foetus being SGA, so that the abdomen palpates as SFD

® it affects growth in the 3rd trimester

• Alcohol and illegal drug use are also causes of being SGA ® so all these factors must be checked inn

the antenatal history

Examination

• BMI should be routinely calculated at the booking visit ® if it is below the normal range, the foetus is at

risk of measuring SFD in the 3rd trimester

• A raised BMI may make it difficult to assess foetal size accurately, as well as increasing the risk of gestational diabetes

• In both situations, it is appropriate to arrange serial growth scans

• General examination should also include checking BP, and urinalysis for proteinuria or glycosuria

• On abdominal palpation in relation to LFD or SFD, the following should be noted:

o Symphysis-fundal height o Number of foetuses

o Foetal lie

o Liquor volume o Presence of uterine fibroids

o Presence of adnexal masses

Investigation

BLOOD TESTS

• In the case of a LFD uterus: o A glucose tolerance test (GTT) should be arranged to establish whether gestational

diabetes has developed

o If polyhydramnios is found in the absence of diabetes, foetal infection may be the cause ®

to maternal antibodies (IgM & IgG) to toxoplasma, rubella, CMV, and herpes should be investigated

• A patient who is SFD and is also hypertensive should be investigated for pre-eclampsia ® the blood

investigations include a FBC, liver & renal function tests, including a uric acid level



ULTRASOUND

• Foetal ultrasound: o Plotting US measurements of biparietal diameter, head circumference, abdominal

circumference & femur length on a growth chart is the main method of monitoring foetal growth o In the case of SFD, then serial measurements, at least 2 weeks apart, should be taken to

distinguish between SGA and IUGR

o There are two types of IUGR: § Typically, asymmetrical IUGR (a discrepancy between the growth of the foetal head

& abdomen) is associated with uteroplacental insufficiency ® the foetus

preferentially diverts blood to the vital organs, and there is less blood to the kidneys

(resulting in reduced liquor production and oligohydramnios), as well as less storage of glycogen in the foetal liver

§ Symmetrical IUGR is more commonly seen in other conditions, e.g. foetal infection

• Placenta / liquor ultrasound: o Trophoblastic disease is usually excluded at the 12-week booking scan by checking the

structure of the placenta ® this condition therefore rarely presents later in pregnancy with a

uterus that palpates LFD

o A scan be also be used to measure the liquor volume objectively ® the amniotic fluid index

(AFI) is the sum of the fluid pockets in the four quadrants of the abdomen, and is normally 8–

18 cm

• Maternal ultrasound:

o USS is useful to diagnose uterine fibroids or the presence of ovarian cysts

DOPPLER STUDIES

• In conjunction with growth scans and measurements of the liquor volume, Doppler waveforms of the blood flow in the uteroplacental and foetoplacental circulation can be used to asses the SGA or IUGR

foetus

• Increased placental vascular resistance, for example in pre-eclampsia, changes the pattern of the

flow in the umbilical artery ® there is normally flow towards the placenta during foetal diastole, but as

placental resistance increases, diastolic flow becomes absent and then reversed

• Other vessels can also be examined within the foetus, including the middle cerebral artery and ductus

venosus ® to look for patterns of flow redistribution if the placental blood flow is insufficient

CARDIOTOCOGRAPHY

• CTG can be used to assess the IUGR foetus ® when not in labour, the tracing might be abnormal when

uteroplacental insufficiency is severe

• The presence of the following should be excluded: o Reduced variability

o Bradycardia o Tachycardia

o Decelerations

• The SGA can only be distinguished from the IUGR foetus by serial growth scans ® further investigation

includes Doppler studies and CTG



Summary

• Algorithm for the diagnosis of a large-for-dates uterus:

• Algorithm for the diagnosis of a small-for-dates uterus:

OBSTETRICS – HYPERTENSION IN PREGNANCY



• Blood pressure problems in pregnancy can be divided into three groups:

o Pre-existing / essential hypertension ® women may present with a known history of

hypertension, or be found to be hypertensive at booking in the 1st trimester

o Pregnancy induced hypertension ® this is hypertension presenting in the later part of the

pregnancy with no proteinuria

o Pre-eclampsia (aka proteinuric pregnancy induced hypertension) ® this is a multisystem

disorder, one manifestation being hypertension with proteinuria, but where renal, liver & clotting

functions may also be affected

• History and examination are aimed at differentiating between these ® remembering that essential

hypertension predisposes to pre-eclampsia

History

PRESENTING COMPLAINT

• The woman is often asymptomatic of her high BP, which is picked up as part of the routine antenatal check

• Symptoms of pre-eclampsia include: o Headache

o Visual disturbance ® in the form of flashing lights, NOT the ‘black dots’ associated with

postural hypotension

o Right upper quadrant or epigastric pain ® due to perihepatic oedema of the liver capsule

o Facial swelling

o Decreased urine output

PAST GYNAECOLOGICAL HISTORY

• A history of high blood pressure when taking the oral contraceptive pill indicates susceptibility to hypertension in pregnancy


• If the blood pressure was high in previous pregnancies because of essential hypertension ® it is very

unlikely to be normal in this pregnancy

• Pre-eclampsia, however, does not always recur with every pregnancy ® it is most common in

primigravida, or in the first pregnancy with a new partner


• Conditions that predispose to hypertension include diabetes, renal & cardiac disease

FAMILY HISTORY

• Pre-eclampsia does ‘run in families’ ® with the strongest association being if the patient’s sister was

affected in her pregnancy

• The more severe the pre-eclampsia and the earlier it occurs, the more likely it is to be familial

DRUG HISTORY

• Some women with hypertension prior to pregnancy might already be on medication ® this might need

to be changed to avoid drugs contraindicated in pregnancy



Examination

GENERAL EXAMINATION

• Severe pre-eclampsia can cause an altered level of consciousness

• Look for facial oedema ® if you are not sure, ask her partner or family member is she looks different

• Check the blood pressure ® this should be measured with the patient sitting or lying, using the

disappearance (rather than the muffling sound) as the cut-off for the diastolic

• Check the reflexes (they will be brisk in pre-eclampsia) and examine for clonus

• Perform fundoscopy to look for papilloedema in pre-eclampsia ® retinopathy might be seen in

severe, chronic cases of essential hypertension

ABDOMINAL PALPATION

• Feel for liver tenderness

• Palpate the uterus to ascertain if the uterine size is appropriate for gestational age ® a SFD uterus is

seen in pre-eclampsia

Investigation

• Urinalysis:

o The urine should be tested using a dipstick ® the presence of proteinuria may be due to pre-

eclampsia, but may also be the result of contamination with blood, liquor (if the membranes have ruptured), or vaginal discharge, or be caused by a UTI

o A UTI should be suspected if the proteinuria is associated with the presence of leucocytes ®

especially if nitrites and/or blood are also present

o Pre-eclampsia should NOT be excluded because of the presence of a UTI ® send an MSU

specimen for MC&S, but continue investigating for pre-eclampsia

o To quantify proteinuria, a 24h urine collection should be performed ® the result is suggestive

of pre-eclampsia if the protein is >0.3 g

• Blood tests:

o Serum uric acid, renal function tests, LFTs, FBC & clotting screen should be assessed ®

the results would be expected to be normal for pregnancy in women with essential hypertension (unless there was an underlying cause such as renal disease), but may become

deranged as pre-eclampsia develops

o In pre-eclampsia, the following abnormalities may be found:

§ ¯ platelets

§ uric acid

§ ALT / AST

§ bilirubin

§ urea & creatinine

§ haematocrit

• Ultrasound:

o Pre-eclampsia may cause IUGR, oligohydramnios, and abnormal Dopplers secondary to

placental insufficiency

o Essential hypertension, if poorly controlled, may also affect foetal growth

• Supplemental investigations: o If there is any suspicion of an underlying cause for the hypertension, it should be further

investigated with a chest X-ray, ECG, echocardiogram, and a 24h urine collection for

creatinine and catecholamines (if phaeochromocytoma is clinically suspected)



Summary

OBSTETRICS – FAILURE TO PROGRESS IN LABOUR


Introduction

• Labour and delivery require the interaction of three components as part of a dynamic process ®

passages, passenger & power:

o Passages ® the shape & size of the hard bony pelvis and soft tissues

o Passenger ® the size, presentation & position of the foetus

o Power ® this is both involuntary (strength & frequency of uterine contractions) and voluntary

(diaphragm and abdominal muscles)

• Any of these factors can be involves in the failure of labour to progress normally

• Once the diagnosis of labour has been made ® a primiparous patient is expected to progress at

approximately 1 cm/hr, and a multiparous patient at 1–2 cm/hr

• A partogram gives a graphical representation of this progress, and hence failure to progress normally can be easily detected:

• Examination and investigation of the causes of prolonged labour should be considered in terms of the

three factors above

History

• The factors that can cause failure to progress (FTP) include:

PASSAGES

• Bony passages ® abnormalities include an abnormally shaped pelvis, or cephalopelvic disproportion

• Soft passages:

o The patient may have previously been diagnosed with uterine fibroids ® a cervical fibroid

can interfere with cervical dilatation



o A previous history of cervical surgery ca cause scarring, which may result in cervical stenosis

® this is particularly relevant with a knife cone procedure, but is less common with the

LLETZ procedure o Female genital mutilation / circumcision usually makes the vaginal introitus smaller, and

thus can affect progression in the second stage of labour

PASSENGER

• It is often useful in a multiparous patient to check the weights of previous deliveries as an assessment of

ability to deliver the current infant

• A history of diabetes, either pre-existing or gestational, increases the risk of foetal macrosomia ® if

the foetal size is out of proportion to the size of the maternal pelvis (known as cephalopelvic

disproportion, or CPD), labour may be slow to progress

• Antenatal diagnosis of a foetal abnormality can inhibit normal progression, for example:

o A congenital goitre causes extension of the neck, so that the normal process of flexion cannot occur

o In anencephaly (a form of spina bifida where the foetal skull fails to develop), the head is less

able to engage, and therefore labour might not progress normally

POWER

• In general, 3–4 uterine contractions every 10 min, each lasting approximately 60 sec, maintain

adequate progress in labour ® the frequency and length of contractions can be assessed by asking the

patient, palpating the maternal abdomen, or checking the CTG

• NB: In the presence of efficient contractions, a malposition of the vertex usually corrects ® this might

require an oxytocin infusion to improve contractions, particularly in a primiparous patient

Examination

• Examination of a patient with FTP should include:

• The examination must also include checking the colour of the liquor to exclude meconium ® this is

relevant when considering foetal wellbeing in a patient who is making slow progress, and should be assessed in conjunction with foetal monitoring

PASSAGES & PASSENGER

• Short stature puts the patient at risk of CPD, and so BMI is calculated ® a raised BMI may make it

difficult to assess foetal size & presentation, as well as increasing the risk of developing gestational diabetes



• At the onset of established labour, the cervix is fully effaced ® however, if progress is slow, it becomes

thicker on palpation as it gets oedematous

• A cervical fibroid should be excluded

• Labour can be slow if the foetus is not in a longitudinal lie ® similarly, a malpresentation or a

malposition can cause FTP

• The uterus should always be palpated to check engagement

• Caput and moulding increase as the progress of the labour slows:

o Caput ® a boggy swelling on the presenting part as subcutaneous scalp oedema develops

o Moulding ® graded according to whether the overlapping of the skull bones is reducible or not

• The station of the presenting part is assessed by its relationship to the ischial spines:

POWER

• Abdominal palpation assesses the following features of the contractions: o Frequency

o Strength o Length

Investigation

• Assessment of the passage and the passenger is made clinically

• CTG can be used to assess frequency and length of uterine contractions ® in conjunction with uterine

palpation to assess strength

• CTG also assesses the risk of foetal hypoxia by giving information on the foetal heart rate

Management

• This depends on the cause

• Artificial rupture of membranes (ARM) is thought to release local prostaglandins and can increase the rate of labour progression

• The strength & frequency of uterine contractions can also be improved by administration of an infusion

of IV syntocinon ® regular strong contractions will help to correct a foetal malposition by rotating the

head against the pelvic floor muscles, as well as improving descent

• However, caution must be exercised in a multiparous patient ® generally, labour proceeds more rapidly

in a second pregnancy, and therefore if progress is slow, foetal size & position must be considered so that excessive contractions do not put the patient at risk of uterine rupture



• If there are good contractions over several hours but without significant progression in terms of cervical

dilatation and descent of the presenting part ® consider delivery by caesarean section

• FTP in the second stage of labour should be assessed in the manner already described, and instrumental delivery considered

• If the head is almost crowning, then an episiotomy might be all that is necessary to expedite vaginal delivery

Summary

OBSTETRICS – ABNORMAL CTG IN LABOUR


Foetal monitoring in labour

• The cardiotocograph (CTG) is a form of electronic foetal heart rate (FHR) monitoring used to evaluate foetal well-being before and during labour

• As well as the FHR, the uterine activity is recorded

• Intermittent auscultation of the FHR may be appropriate for a healthy woman in labour who has had an

uncomplicated labour ® this involves documenting the heart rate for a minimum of 60s at least:

o Every 15 min in the first stage of labour

o Every 5 min in the second stage of labour

• Continuous monitoring might be recommended if any abnormal features develop, or any risk factors

develop ® e.g. meconium-stained liquor

• Indications for recommending continuous CTG monitoring include:

Features of the CTG

• There are several features of the CTG, which should all be assessed individually and then taken together with the clinical picture to determine the appropriate management of the patient (DR C

BRAVADO):

o Define Risk o Contractions

o Baseline Rate

o And o Variability

o Accelerations

o Decelerations

o Overall impression

• For example, slow progress in labour or the presence of meconium-stained liquor might prompt more timely intervention

o Baseline FHR:

§ This is the mean level of FHR over a period of 5 to 10 min



§ It is expressed as bpm, and is determined by the foetal sympathetic and

parasympathetic systems

§ The normal range is 110-160 bpm ® in the preterm foetus, the baseline tends to be

at the higher end of the normal range

o Baseline variability:

§ Minor fluctuations occur in the baseline FHR at 3 to 5 cycles per minute § It is measured by estimating the difference in bpm between the highest and lowest

trough of change in a 1 min segment

§ Normal baseline variability is ≥5 bpm o Accelerations:

§ These are increases in the FHR of ³15 bpm, lasting ³15s

§ These are a feature of a normal CTG

o Decelerations: § These are falls in the FHR below the baseline of >15 bpm, lasting ≥15s or more

§ Different patterns of decelerations can be seen, depending on their timing with the

uterine contractions:

• Early decelerations ® the FHR slows at the same time as the onset of

contraction and returns to the baseline at the end of the contraction

• Late decelerations ® the FHR begins to fall during the contraction, with its

trough >20s after the peak of thee contraction, and returning to baseline after

the contraction

• Variable decelerations ® the timing of the slowing of the FHR in relation to

the uterine contraction varies, and can occur in isolation ® there is typically

rapid onset and recovery ® however, some features might make this type of

deceleration more suspicious, such as loss of the normal baseline variability

• Sinusoidal pattern ® there is regular oscillation of the baseline, with absent

variability ® the pattern lasts at least 10 min, and has an amplitude 5–15

bpm above and below the baseline

• The CTG can be categorised into:

o Normal ® all four features are reassuring

o Suspicious ® one feature is non-reassuring, the others are reassuring

o Pathological ® two or more features are non-reassuring, or more than one is abnormal

Category Baseline (bpm) Variability (bpm) Decelerations Accelerations

Reassuring 110–160 ≥5 None present Present

Non-reassuring 100–109 161–180

<5 for ≥40 min Early decelerations Variable decelerations Single deceleration <3 min

None

Abnormal <100 >180 Sinusoidal pattern

<5 for ≥90 min ≥10

Late decelerations Single deceleration >3 min

None

Physiology

• The principle of monitoring during labour is to detect foetal hypoxia, and therefore prevent acidaemia and cell damage



ACUTE FOETAL HYPOXIA

• This can occur secondary to: o Uterine hyperstimulation

o Placental abruption o Umbilical cord compression

o Sudden maternal hypotension ® e.g. insertion of regional anaesthesia

• These conditions can result in a decrease in the FHR, with decelerations or bradycardia ® this is

produced by chemoreceptor-mediated vagal stimulation, and then by myocardial ischaemia

CHRONIC FOETAL HYPOXIA

• If there has been chronic uteroplacental insufficiency during the pregnancy (e.g. secondary to pre-

eclampsia) ® then the foetus might be at increased risk of hypoxia during labour

• Reduced intervillous perfusion during uterine contractions or maternal hypotension can exacerbate

underlying reduced placental perfusion ® this can result in an increased baseline rate, followed by

reduced variability due to brainstem hypoxia

• Continuing hypoxia eventually produces myocardial damage and decelerations

Monitoring uterine contractions

• As well as monitoring the FHR, the CTG also monitors the frequency of uterine contractions

• This can be important, for example, if the patient is having IV syntocinon to stimulate the contractions

® it is essential that frequency of contractions and the return to resting tone between contractions is

noted

• The actual strength and length of each contraction should be checked by palpation of the uterus ®

because the size of the peaks on the tracing may be related to the positioning of the monitor on the

maternal abdomen, or thickness of the maternal abdominal wall

History

• The need to act on an abnormal CTG in labour is influenced by maternal, foetal & intrapartum factors

• The indications for continuous CTG monitoring are also the relevant points in the patient’s antenatal

history that might make the physician more concerned if the CTG is suspicious

• Particularly important are the intrapartum factors:

o In the presence of meconium-stained liquor ® the CTG should be acted upon promptly

o If the cervix is undilated ® foetal blood sampling is not possible

o If there is failure to progress ® then operative delivery might be necessary

Examination

BASELINE MATERNAL OBSERVATIONS

• Temperature: o A raised maternal temperature might explain foetal tachycardia

• Pulse: o This might be raised in conjunction with maternal pyrexia

o In the presence of foetal bradycardia ® maternal pulse should be checked to ensure that the

monitoring is recording FHR and nor maternal



• Blood pressure:

o Epidural anaesthesia can be associated with maternal hypotension as it is administered ®

this results in reduced blood flow to the uterus, and can cause foetal bradycardia

o Therefore, IV fluids are administered, and the BP checked regularly when the medication is given

ABDOMINAL PALPATION

• The following features should be checked on palpation: o Uterine size

o Engagement of presenting part o Scar tenderness in a patient with a previous CS

o Uterine tone

• The size of the maternal abdomen should be assessed to check if it is large or small for dates

• The engagement of the presenting part is important to assess progress in labour

• In a patient who has previously had a CS, the presence of scar tenderness should be elicited ® scar

rupture is commonly associated with an abnormal CTG and vaginal bleeding

• Another cause of vaginal bleeding with an abnormal CTG is placental abruption ® if this is suspected,

the uterus will typically feel hard & tender

• The uterine contractions should be palpated, especially if the patient’s labour is being stimulated by IV

syntocinon ® it is important to check that that uterus is not hyperstimulated, as this can cause an

abnormal FHR (there should be resting tone between contractions)

VAGINAL EXAMINATION

• As well as assessing the dilatation of the cervix to determine the progress in labour and the ability to

perform a foetal blood sample ® the presence of the foetal cord must be excluded

• A cord prolapse is associated with foetal bradycardia ® this is an emergency situation requiring

immediate delivery by caesarean section if the cervix is not fully dilated

Investigation

• If the CTG is suspicious ® the patient can be managed conservatively

• If the CTG is pathological ® foetal blood sampling (FBS) should be performed if there are appropriate

facilities:

o The procedure is performed with the mother in the left lateral position, and the cervix should be

dilated at least 2cm

o A sample of blood from the foetal scalp gives the foetal pH (a measure of acidosis) ® it might

indicate that delivery is necessary (pH ≤7.20), or that the test should be repeated within 30 min

(pH 7.21–7.24)

• If FBS is not possible ® delivery should be expedited

• Contraindications to FBS include:

o Maternal infection ® HIV, Hep B, herpes simplex

o Foetal bleeding disorder ® haemophilia, thrombocytopaenia

o Prematurity ® <34 weeks



Summary

OBSTETRICS – POSTPARTUM HAEMORRHAGE



• Postpartum haemorrhage (PPH) is bleeding from the genital tract of >500 ml after delivery of the infant

• It is classified as either primary or secondary:

o Primary PPH ® bleeding > 500 ml within 24 hours of delivery

o Secondary PPH ® bleeding >500 ml that starts after 24 hours and occurs within 6 weeks

• In practice, blood loss of more than 1000 ml is more clinically relevant

• Most units classify bleeding of more than 2000 ml as massive obstetric haemorrhage ® there is

usually a specific local protocol for management

• The differential diagnosis that should be considered include:

Type of PPH Differential diagnosis

Primary Uterine atony Genital tract trauma ® cervix / vagina / perineum Retained placenta / placenta accrete Coagulation disorders Uterine inversion Uterine rupture

Secondary Retained products Endometritis Persistent molar pregnancy / choriocarcinoma

• About 90% of cases of PPH are caused by uterine atony ® ~7% are due to genital tract trauma

History

PRIMARY PPH

• Uterine atony: o Risk factors in the patient’s history that suggest an increase in the risk of a primary PPH

secondary to uterine atony include:

§ Multiple pregnancy

§ Grand multiparity § Foetal macrosomia

§ Polyhydramnios

§ Fibroid uterus § Prolonged labour

§ Previous PPH

§ Antepartum haemorrhage

o In a multiple pregnancy, the placental site is larger than with a singleton ® there is

overdistension of the uterus, which is also seen in cases of macrosomia and

polyhydramnios

• Mode of delivery: o The mode of delivery may increase risk of PPH

o Genital tract trauma can occur with a normal vaginal delivery, either from an episiotomy or from a vaginal or cervical tear

o Bleeding is more common with an instrumental delivery ® especially forceps, in particular

Keilland’s forceps



o Average blood loss at CS is 500 ml ® placenta praevia or a prolonged labour may increase

this

§ In the latter, the presenting part may become impacted in the pelvis, making delivery

more difficult ® this can cause the incision on the uterus to tear, which may increase

blood loss

o Rarely, PPH is secondary to uterine inversion that occurs after delivery of the placenta ®

with bleeding, the patient complains of abdominal pain, which can be severe, associated with a feeling of prolapse

o Uterine rupture is also uncommon ® except in associated with labour in a patient who has

previously had a CS

• Other causes: o Coagulation disorders can be acute or chronic

o The chronic conditions (e.g. inherited vascular disorders) are usually known about antenatally o DIC can present acutely, secondary to placental abruption or severe pre-eclampsia

SECONDARY PPH

• In the presence of retained products of conception (either placenta or membranes) ® the common

presenting complaint is prolonged heavy vaginal bleeding or persistent offensive discharge

• In the presence of infection ® the patient may also present with fever and lower abdominal pain

• A molar pregnancy also presents with persistent vaginal bleeding

• Choriocarcinoma, though rare, may metastasise to the lungs, liver or brain ® presenting symptoms

include haemoptysis & dyspnoea, or neurological symptoms

Examination

PRIMARY PPH

• The blood loss must be estimated as accurately as possible to manage the patient appropriately

• Examination must include the ABC of basic resuscitation, as well as pallor, pulse and BP

• Abdominal palpation should assess whether the uterus is contracted or not

• The fundal height should be at or below the umbilicus ® if it is above, there might be retained

products of conception, or the uterus could be filling with clots

• Uterine inversion should be considered if the fundus is indented or cannot be palpated ® vaginal

examination will assess the degree of inversion, either up to the cervical os or complete inversion of the uterus & vagina

• If the uterus is well contracted and the placenta is out, then the bleeding might be from genital tract

trauma ® the patient should be examined in sufficient light and with adequate analgesia (either general

or local) to exclude lacerations to the cervix, vagina & perineum

• If the placenta and membranes have been delivered, they must be carefully examined to see that the cotyledons appear complete, and that there is no suggestion of a succenturiate lobe

• Overall, the examination should include: o ABC

o Amount of blood loss o Pulse

o BP

o Urine output

o Uterine contraction

o Fundal height o Placenta & membranes complete

o Genital tract trauma



SECONDARY PPH

• Basic observations should include pulse, BP & temperature ® tachycardia & pyrexia may be present

with endometritis

• The fundal height should be checked because the uterus will usually remain poorly contracted if there are retained products of conception

• Tenderness should be excluded to rule out endometritis

• Speculum examination excludes vaginal discharge if there is suspicion of infection

• Bimanual palpation examines the size of the uterus ® it may be bulky with retained products or a

molar pregnancy

• If the cervical os is open ® there might be retained products

Investigation

PRIMARY PPH

• Having established IV access, blood should be sent for haemoglobin, platelets, clotting screen, and

group-and-save ® depending on estimated blood loss, a crossmatch might be necessary

• U&Es should be tested if the urine output is poor

SECONDARY PPH

• An FBC should be taken to estimate haemoglobin ® a raised WBC is an indication of infection

• Crossmatching blood might be necessary, depending on the clinical situation and haemoglobin result

• A high vaginal swab should be taken to exclude endometritis

• An USS should be arranged to check that the uterus is empty & exclude retained products, including

molar tissue ® care should be taken to interpret the findings in conjunction with the clinical picture, as

blood clots might have a similar scan appearance

• The diagnosis of molar pregnancy is confirmed with a persistently raised b-hCG ® evacuation of the

uterus will yield tissue for histological analysis to confirm the diagnosis, and exclude choriocarcinoma

o If the latter is confirmed, LFTs and a chest X-ray should be performed to check for metastases

Summary

• An algorithm for the diagnosis of primary PPH:



• An algorithm for the diagnosis of secondary PPH:

OBSTETRICS – STILLBIRTH


Introduction

• The term ‘stillbirth’ is used to describe the intrauterine death of a foetus after 24 weeks’ gestation, which is diagnosed before or during labour, or at delivery

• The woman might present with symptoms of the event that caused the baby to die, or simply attend because she has not felt foetal movements

• Common causes of stillbirth include:

• If foetal death is suspected antenatally ® an USS is performed to look for absence of foetal heart

activity

• It is recommended that the finding of intrauterine death is confirmed by a second sonographer

• The rate of stillbirth varies with maternal age ® from 5.5 per 1000 deliveries for <25yrs, to 14 per 1000

deliveries for ³45yrs

History

• Finding out when the mother last felt foetal movements can help to work out how recently foetal death

occurred ® but this will not help with the diagnosis of the underlying cause unless it can be linked to a

particular occurrence

HISTORY OF THE PREGNANCY

• The following points might be helpful:

o Rhesus group ® if the woman is Rhesus negative then Rhesus disease is a possibility ® the

mother might suddenly describe feeling bigger due to polyhydramnios

o Down syndrome screening ® if the woman is high risk, a chromosomal abnormality might be

present

o Ultrasound for anomaly / growth ® any structural abnormalities or a history of IUGR

increases the risk of stillbirth

o Recent antepartum haemorrhage ® repeated small abruptions can compromise foetal

wellbeing and cause IUGR ® abruption is painful, so ask about bleeding and pain



o Ruptured membranes allow infection to ascend and infect the membranes and placenta

(chorioamnionitis), and therefore the foetus ® ask about any leaking of fluid

o Obstetric cholestasis causes a characteristic pattern of itching, particularly affecting the palms of the hands and the soles of the feet

• Signs of maternal illness (fever, feeling unwell, flu-like symptoms, GI upset) are also suggestive of foetal

infection ® listeria, toxoplasma and parvovirus can cause only very mild illness in the mother, but

death in the foetus


• If the woman has had a previous stillbirth, it is important to find out if an underlying cause was

discovered

• Rhesus disease gets more severe with successive pregnancies ® so a first child might be unaffected,

or suffer only mild jaundice

• Gestational diabetes in a previous pregnancy is likely to recur


• Maternal conditions such as diabetes and renal disease increase the risk of stillbirth

• A personal or family history of thrombosis might point to an underlying thrombophilia

Examination

GENERAL EXAMINATION

• The mother’s pulse, BP and temperature are taken ® maternal infection may cause tachycardia and

pyrexia

• A significant bleed due to abruption or bleeding placenta praevia may cause hypovolaemic shock

• The itching of cholestasis might be evident from scratch marks on the skin, but there is no rash

EXAMINATION OF THE UTERUS

• Assess the following:

o Uterine size ® small-for-dates suggests IUGR, or that the foetus died some time ago ® large-

for-dates might be due to polyhydramnios (e.g. diabetes, Rhesus disease, twin-to-twin

transfusion syndrome)

o Uterine consistency ® abruption causes the uterus to feel tense, tender & hard, and it might

be irritable (i.e. palpation provokes contractions) ® with chorioamnionitis the uterus will be

soft & tender, and might be irritable

o Foetal presentation ® breech presentation is associated with foetal abnormality and cord

prolapse

Investigations

URINALYSIS

• The urine is tested by dipstick, looking particularly for protein as a sign of pre-eclampsia

• If significant proteinuria is found ® a 24h collection must be commenced, and an MSU sent to exclude

infection

BLOOD TESTS

• FBC and group-and-save should be sent due to the risk of DIC following stillbirth



• HbA1c ® if raised, this suggests maternal diabetes

• Coombs’ test ® to look for evidence of Rhesus disease

• Infection screen ® blood cultures and antibody levels for toxoplasma, parvovirus, listeria & syphilis

• Kleihauer test ® looks for evidence of foetomaternal haemorrhage, as can occur with abruption

• Thrombophilia screen

ULTRASOUND SCAN

• Once the diagnosis of foetal death has been made, a scan will not add much information ® unless the

parents do not wish for a post-mortem of the baby

• In this case, the scan is an opportunity to look for evidence of internal structural anomalies

PATHOLOGY

• Parents are encouraged to allow post-mortem examination of their baby, so that all possible information is collected

• They should be reassured that this will not prevent them from arranging a funeral or cremation for the baby

• Post-mortem includes examination of the placenta and a foetal karyotype

• If the parents do not consent to the full post-mortem ® they should be offered a more limited

examination comprising X-rays and external examination of the baby, or solely examination of the

placenta

Management

• In most cases, labour is induced using prostaglandins and/or IV syntocinon

• Occasionally, a caesarean section may be required if the mother is unwell and delivery needs to be

expedited, or because induction of labour would pose a significant risk ® e.g. if the mother had several

CS in the past

• Some women will opt to continue the pregnancy, and more than 90% will spontaneously labour within 3

weeks ® by 4 weeks after foetal death, there is a 1 in 4 risk of developing DIC, so these women should

have their platelet levels and clotting studies monitored regularly

• After delivery, the parents should be encouraged to hold their baby if they so wish

• Footprints, handprints & photographs can be taken, and the parents might choose to have some form of blessing or religious ceremony at this stage

• The mother may be prescribed cabergoline to suppress lactation

Follow-up

• Psychological and social support is extremely important ® prior to the woman leaving the hospital, the

GP & community midwife should be informed, and any antenatal clinic appointments cancelled

• The mother should be seen for at least 10 days by the midwife for postnatal checks

• Information about parent support groups (e.g. SANDS) should be given

• A follow-up appointment should be made with the consultant, who often chooses to see the parents in

the gynaecology rather than antenatal clinic ® all the results will be reviewed, and any questions can be

answered, even if only to explain that the stillbirth was unexplained

OBSTETRICS – MATERNAL COLLAPSE


Introduction

• Collapse of a pregnant patient might have an obstetric or a non-obstetric cause

• The danger is to prioritise delivery because of fears for the foetus

• However, it is important to remember that maternal resuscitation is the single most effective means of

improving foetal health ® delivery, if necessary, should ONLY be contemplated when the mother is

stable

• The principles of first-line management are the same (ABC approach), and foetal monitoring should be established once the mother’s initial resuscitation has commenced

Haemorrhage

• Antepartum haemorrhage sufficient to cause collapse will usually be due to placental bleeding ®

either placental abruption or placenta praevia o Placental abruption presents with pain, and a tense, hard & tender uterus

o Placenta praevia presents as painless, with a soft & non-tender uterus

• Uterine rupture can also cause collapse with bleeding

• Postpartum haemorrhage causes include uterine atony, RPOC, genital tract trauma, and clotting

abnormalities

PLACENTAL ABRUPTION & PLACENTA PRAEVIA

• Major obstetric haemorrhage can be extremely rapid and is potentially fatal ® so coordinated

management is vital

• Abruption severe enough to cause collapse or foetal distress is likely to be associated with blood loss of at least 1500 ml, and a 30% incidence of coagulopathy

o NB: APH from abruption or placenta praevia predisposes to PPH

• It can be difficult to control bleeding from the placental site during caesarean section for placenta

praevia ® syntocinon infusion is used, but further measure might be required, including:

o Ergometrine

o The prostaglandin analogues carboprost (Hemabate) and misoprostol o Bimanual compression

o B-Lynch sutures

o Internal iliac ligation o Arterial embolisation

o Hysterectomy

UTERINE RUPTURE

• Uterine rupture is uncommon ® occasionally, trauma might be the cause, but more commonly the

woman is multiparous and in labour

• Those most at risk are women with a scar on the uterus, usually a previous CS ® using a syntocinon

infusion in this situation increases the risk still further

• Signs and symptoms include: o Severe scar pain & tenderness

o Constant pain ® between contractions

o PV bleeding

o CTG abnormalities



o Bloodstained liquor

o Haematuria

• Resuscitation and laparotomy are needed

UTERINE ATONY

• When the uterus fails to contract following delivery of the placenta ® the blood vessels that supplied the

placenta are not constricted by compression, so uterine bleeding continues

• Risk factors include:

o Precipitate labour ® <2 hours

o Induced labour

o Augmented labour ® i.e. syntocinon infusion

o CS following prolonged / augmented labour o Magnesium sulphate treatment

o Multiple pregnancy

o Chorioamnionitis

• If medical treatment (syntocinon, ergometrine, Hemabate) fails ® consider packing the uterus,

radiological artery embolisation, or surgery

Amniotic fluid embolism

• This poorly understood condition results in transient pulmonary hypertension, profound hypoxia, left

ventricular failure, and secondary coagulopathy

• Foetal and maternal mortality is high

• The use of syntocinon and precipitate labour are known to be risk factors ® but amniotic fluid

embolism (AFE) can also occur in non-augmented labours

• The diagnosis might only be discovered post-mortem, but could also be made on the basis of the

characteristic trio of: o Cyanosis

o Collapse

o Clotting derangement ® DIC

• Management consists of ventilatory support and correction of the coagulopathy

Acute myocardial infarction

• Antenatal myocardial infarction (MI) carries a mortality of up to 45%

• The resuscitation algorithm is the same as that for non-pregnant adults ® but the woman must be tilted

onto her left side to reduce the compression of the vena cava by the pregnant abdomen

• It is felt that if the foetus is compromising the resuscitation ® delivery should be achieved

• A senior cardiologist should be involved at an early stage

Eclampsia

• In summary, the management of eclampsia begins with controlling the fit ® IV magnesium sulphate is

started as prophylaxis against further fits

• The BP must be reduced to MAP levels of <125 mmHg

• Delivery of the foetus should be considered at this point



Diabetic emergency

• In the acute setting, diabetic coma is more likely to be due to hypoglycaemia ® especially as

glycaemic control in pregnancy & postnatally can be difficult, and fasting blood glucose levels are lower

• Hyperosmolar non-ketotic coma might be seen in a diabetic woman who has been unwell at home for

some time

HYPOGLYCAEMIA

• Infuse 50 ml 50% dextrose IV over a short space of time, followed by a saline flush

• Check the blood glucose again after 15 minutes

• Once the woman is conscious, a 20 g glucose drink is given, followed by a longer-acting carbohydrate

snack or meal

• The blood glucose should be rechecked 1 hour later

HYPERGLYCAEMIA

• Rehydration, an insulin infusion, and hourly assessment of serum potassium levels are the main aims of treatment

• Foetal monitoring might show a non-reassuring CTG ® this is likely to improve as ketosis is corrected

Drug toxicity

• Maternal collapse could be due to overdose, adverse effects, or allergy to drugs, or as a result of drug abuse by the patient

LOCAL ANAESTHETIC

• High spinal anaesthesia occurs when a very high dose of local anaesthetic is given, or due to

inadvertent intravascular injection at the time of epidural anaesthesia

• Respiratory muscle paralysis requiring ventilation results

• Warning signs include hypotension, nausea, dizziness, and dyspnoea

ANALGESIA

• Opiates such as pethidine, morphine & diamorphine are used for pain relief in labour ® in high doses

they can cause respiratory depression

• Naloxone will immediately reverse respiratory depression, but has a short duration ® so a further dose

might be needed

• NSAIDs are commonly used for postnatal analgesia ® these can precipitate bronchoconstriction in

asthmatics ® a severe asthma attack should be treated with IV hydrocortisone and nebulised

salbutamol, and ventilatory support might be necessary

MAGNESIUM

• Magnesium sulphate is used following eclampsia as prophylaxis against further seizures

• Hypermagnesaemia can result in coma

• The signs of magnesium toxicity, in order of increasing Mg levels, include: o Loss of patellar reflex

o Flushing

o Slurred speech

o Motor weakness



o Respiratory depression

o Cardiac arrest

• Calcium gluconate is used to treat toxicity

DRUG ABUSE

• Opiates, ecstasy & cocaine can all cause collapse and coma

• Convulsions can result from ecstasy or cocaine use ® these may be treated with diazepam

• Opiate-induced respiratory depression is treated with naloxone

Puerperal sepsis

• Septic shock can cause collapse

• There should be an attempt to establish the focus of infection ® paying particular attention to the

possibility of RPOC

• Empirical broad spectrum antibiotic therapy should be started without delay, and without waiting for microbiology results

• A septic screen (blood culture, MSU, chest X-ray, and swabs) should be performed

• Renal, respiratory & cardiac failure can ensure ® and DIC often accompanies severe sepsis

Thromboembolism

• Pregnancy is a prothrombotic state, and thromboembolism is one of the most common causes of maternal mortality

PULMONARY EMBOLISM

• Smaller Pes will cause dyspnoea and pleuritic pain ® but larger emboli can present with collapse

• On examination ® the following may be found:

o Tachypnoea o Tachycardia

o Raised JVP o Loud second heart sound

• The investigation of PE includes:

o ABGs ® to look for low PO2 and PCO2

o Chest X-ray ® to exclude infection

o ECG

o VQ scan / spiral CT ® to identify the clot

• Anticoagulation with heparin is the normal treatment ® but a PE large enough to cause collapse may

merit treatment with streptokinase

o NB: In pregnancy, ABG and ECG may be normal with a small PE ® so if there is doubt, start

treatment and request imaging (VQ scan / spiral CT)

CEREBRAL VENOUS THROMBOSIS

• This condition is uncommon, but is associated with a high mortality

• It usually occurs in the puerperium (the 6–8 weeks postnatally)

• There might be focal neurological signs, but signs can be more general ® these include

convulsions, headache, photophobia, and vomiting ® there might be a fever and raised WCC

• Diagnosis is made on CT or MRI

• Convulsions should be treated, the patient kept well hydrated, and heparin therapy considered



Summary

xss28 - obstetrics

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