Phase 3A Jonathan Borland amp Rajiv Joshi The Peer Teaching Society is not liable for false or misleading information What we will cover tonight Antenatal screening bloods USS Downs syndrome etc ID: 931483
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Slide1
Obstetrics 1 – AntenatalPhase 3A
Jonathan Borland & Rajiv Joshi
The Peer Teaching Society is not liable for false or misleading information.
Slide2What we will cover tonightAntenatal screening – bloods, USS, Down’s syndrome etcRhesus diseaseInfections
Complications of pregnancy;Miscarriages
Ectopic pregnanciesMolar pregnanciesMaternal disorders – especially pre-eclampsia and other hypertensive diseases Obstetric shock – APH, disorders of the placenta, include PPH here
Slide3Antenatal ScreeningQuestion 1: When is the first US scan performed and what does the obstetrician check for during this exam?Question 2:
What two tests are used to screen for the presence of Down’s syndrome?
Slide4Antenatal ScreeningQuestion 1: Performed 11-13 weeks. Checks for presence of foetus, number of foetuses, heartbeat, crown rump length, nuchal translucency, ovaries.
Question 2: Combined test and Quadruple test.
Slide5Antenatal ScreeningQuestion 3: What are the 3 components of the combined test?Question 4:
What are the 4 components of the quadruple test?
Slide6Antenatal ScreeningQuestion 3: Nuchal tanslucency, PAPP-A, beta-hCG.
Question 4:
AFP, Inhibin A, oestrodiol, beta-hCG.
Slide7Antenatal ScreeningQuestion 5: If the test results of the combined / quadruple test come back as positive, what two invasive investigations can be used to definitively diagnose Down’s syndrome?
Question 6: What is the risk of miscarriage of each of these investigations?
Slide8Antenatal ScreeningQuestion 7: Amniocentesis and Chorionic Villous SamplingQuestion 8:
Amniocentesis: 1% miscarriage risk.
CVS: 1-2% miscarriage risk.
Slide9Antenatal Screening - SummaryCombined Test (11-14 weeks)
Nuchal translucency + PAPP-A +
β-hCGQuadruple Test (14-20 weeks)AFP, Inhibin A, Oestrodiol, β-hCG.AmniocentesisRemoval of amniotic fluid using fine gauge needle under US guidance.Diagnosis of chromosomal abnormalities, infections e.g., CMV, toxoplasmosis, SCD, CF (karyoptying 3 weeks)
Chorionic
Villous Sampling
Biopsy of
trophoblast
.
Faster results than amniocentesis (2 days)
What
abnormalities can Antenatal Screening Detect?
Down’s syndrome;
Trisomy
13;
Trisomy
18; Sex chromosome abnormalities e.g.,
Klinefelter’s
, Turner’s; neural tube defect,
oligo
and
polyhydramnios
, foetal
hydrops
.
Slide10MiscarriageQuestion 7: What is the definition of a miscarriage?Question 8:
Before what week do the majority of miscarriages occur?
Question 9: List the 6 types of miscarriage.
Slide11MiscarriageQuestion 7: Foetus dies or delivers dead before 24 weeks.Question 8:
Majority occur before 12 weeks.Question 9:
Threatened, inevitable, incomplete, complete, septic, missed.
Slide12MiscarriageQuestion 10: What is this type of miscarriage and why?
Slide13MiscarriageQuestion 10:
THREATENED.PV Bleeding
Foetus still aliveUterus is the size expected from the dates.Os is closed.25% miscarry.
Slide14MiscarriageQuestion 11: What is this type of miscarriage and why?
Slide15MiscarriageQuestion 11: INEVITABLEHeavier bleeding
Foetus may still be alive.
Os is open.Miscarriage about to occur.
Slide16MiscarriageQuestion 12: What is this type of miscarriage and why?
Slide17MiscarriageQuestion 12: INCOMPLETESome foetal parts have been passed but not all.
Os is open.
Slide18MiscarriageQuestion 13: What is this type of miscarriage and why?
Slide19MiscarriageQuestion 13: MISSEDFoetus has died in utero and this has not been recognised until scan is performed.
Uterus is smaller than expected for datesOs is closed.
Slide20MiscarriageQuestion 14: What is this type of miscarriage and why?
Slide21MiscarriageQuestion 14: COMPLETEAll foetal tissue has been passed
Bleeding diminishedUterus no longer enlarged
Cervical os is closed
Slide22MiscarriageQuestion 15: Describe the features of a septic miscarriage.Question 16:
In what three ways can a miscarriage be managed?
Slide23MiscarriageQuestion 15: Contents of the uterus are infected leading to endometritis, vaginal discharge is offensive, uterus is tender, fever may be absent and may progress to peritonism
. Question 16:
expectant, medical or surgical.
Slide24MiscarriageQuestion 17: What is the expectant management of a non-viable pregnancy?Question 18:
What drug is used in the medical management of a non-viable pregnancy and how is the surgical management carried out?
Slide25MiscarriageQuestion 17: Can be continued as long as woman is willing. Must be no signs of infection.
Question 18: Medical management is via misoprostol
(prostaglandin) sometimes preceded by the oral anti-progesterone mifepristone and surgical is via ERPC. And obviously patient support, education and reassurance. Anti-D given to women who are rhesus negative.
Slide26MiscarriageQuestion 19: What is the definition of a recurrent miscarriage? Question 20:
What are two causes of late miscarriages (i.e., those occurring beyond 16 weeks)?
Slide27MiscarriageQuestion 19: 3 or more miscarriages occurring in succession.Question 20:
Cervical incompetence and infection (often bacterial vaginosis).
Slide28MiscarriageQuestion 21: List 4 other causes of miscarriage.
Slide29MiscarriageQuestion 21: Antiphospholipid syndrome, chromosomal abnormalities, anatomical factors (bicornuate uterus), infection, obesity, PCOS, older maternal age.
Slide30Maternal InfectionsQuestion 22: What mnemonic is used to remember the perinatal infections that account for 2-3% of all congenital anomalies?
Slide31Maternal InfectionsQuestion 22: TORCHToxoplasmosis
Other (syphilis, VCZ, parovirus
B19)RubellaCMVHerpes Infections
Slide32Maternal InfectionsQuestion 23: What is the name of the protozoan responsible for toxoplasmosis?Question 24:
What is the text-book source of the toxoplasmosis protozoan?
Slide33Maternal Infections Question 23: Toxoplasma gondii
Question 24: Cat faeces (also raw meat).
Slide34Maternal Infections Question 25: What are the foetal effects of a perinatal toxoplasmosis infection?
Question 26 (PAEDS QUESTION): List 3 other names for parvovirus B19 infection.
Slide35Maternal InfectionsQuestion 25: Mental retardation, convulsions, spasticities, visual impairment – affects the brain.
Question 26: Slapped check syndrome, fifth disease, erythema
infectiosum.
Slide36Maternal Infections Question 27: What is the foetal effect of a perinatal parvovirus B19 infection and how might you detect any complications of such an infection during pregnancy?
Question 28: What percentage of parvovirus B19 infections result in foetal death?
Slide37Maternal Infections Question 27: Suppresses foetal erythropoiesis causing anaemia (can be detected on USS - hydrops).
Question 28: Foetal death in 10% of cases; usually before 20 weeks.
Slide38Maternal Infections Question 29: What would be revealed in a USS in a foetus with CMV infection?Question 30:
How does foetal CMV infection typically present?
Slide39Maternal Infections Question 29: USS show hepatic / cranial calcification.Question 30: IUGR; pneumonia; thrombocytopenia; hearing, visual and mental impairment.
Slide40Maternal Infections Question 31: A maternal infection with herpes zoster how many weeks before delivery is associated with severe neonatal infection?Question 32:
What is the name of the spirochaete responsible for syphilis infection?
Slide41Maternal Infections Question 31: 4 weeks.Question 32: Treponema
pallidum.
Slide42Maternal Infections Question 33: What are the foetal consequences of maternal syphilis infection during pregnancy?Question 34:
What is the recommended mode of delivery in a foetus seen in herpes simplex infection?
Slide43Maternal Infections Question 33: Causes miscarriage, severe congenital disease or still birth. Question 34:
Herpes simplex infection is not teratogenic. Transmission during birth with high mortality if neonate becomes infected. C-section recommended if delivering within 6 weeks of primary attack.
Slide44Maternal Infections Question 35: Why can’t a pregnant woman eat the following foods during pregnancy? Name the responsible pathogen.
Slide45Maternal Infections Question 35: Why can’t a pregnant woman eat the following foods during pregnancy? Name the responsible pathogen.
Listeria
monocytogenesToxoplasma gondiiSalmonella
Slide46Rhesus DiseaseQuestion 36: What is red blood cell isoimmunisation and when does it happen?Question 37:
Why is anti-D called anti-D?
Slide47Rhesus DiseaseQuestion 36: When the mother mounts an immune response against antigens on foetal red cells that enter her circulation. The resulting antibodies then cross the placenta and cause foetal red cell destruction.
Slide48Rhesus DiseaseQuestion 37: What is the D refer to in anti-D?
Slide49Rhesus DiseaseQuestion 37: The rhesus system consists of 3 linked gene pairs; one allele of each pair is dominant (C/c, D/d
, E/e). One allele of each pair is inherited (Mendelian
inheritance). The important one is the D gene. Only those who are DD or Dd express the D antigen and a ‘D rhesus positive’. Those who are dd are rhesus negative and will immunological recognise th D antigen as foreign if exposed.
Slide50Rhesus DiseaseQuestion 38: What percetange of Caucasian women are rhesus negative and what percentage of these will mount an anti-D response?
Question 39: If an anti-D response is mounted, what symptoms, signs and complications might you observe?
Slide51Rhesus DiseaseQuestion 38: 15% of Caucasian women are rhesus negative and 1.7% of these will mount an anti-D response.Question 39:
Haemolysis causes anaemia. Neonatal jaundice with or without anaemia if less severe but hydrops and foetal death if severe.
Slide52Rhesus DiseaseQuestion 40: How is rhesus disease identified?Question 41: How is the severity of rhesus disease assessed?
Slide53Rhesus DiseaseQuestion 40: Unsensitised women are screened for antibodies at booking and at 28 weeks’ gestation.Question 41:
Pregnancies at risk of foetal anaemia are assessed using US. Doppler of foetal middle cerebral artery, foetal blood sampling to confirm.
Slide54Rhesus DiseaseQuestion 42: How is rhesus disease treated?Question 43: In all
neoantes bron to rhesus-negative women, what blood tests should be performed?
Slide55Rhesus DiseaseQuestion 42: in utero transfusion if foetus is anaemia, and deliver if < 36 weeks.
Question 43: Should have blood group checked, FBC, blood film and bilirubin
. A coomb’s test is no longer advised.
Slide56Complications of pregnanciesEctopic pregnancies• Maternal disorders – especially pre-eclampsia and other hypertensive diseases • Obstetric shock – APH
Slide57Slide58Ectopic PregnancyThis came up as a SAQ in 2013What is EP?How common is EP as a % of all pregnancies?Mortality rate (/100,000)?Commonest gestational age to present?
Slide59EP is when the embryo implants outside the uterine cavity*1-2% (1 in 60-100)17/100,0008 weeks*Not strictly true, see next slide
Slide60Ectopic PregnancyWhat is the commonest site for ectopic pregnancy?Name 2 other sites for EP
Slide61Slide62EPWhy is it a problem if an embryo implants into the fallopian tube? Won’t it just grow there happily?
Slide63EPThe fallopian tube is thin walled therefore trophoblastic invasion can lead to bleeding into the lumen or may rupture which can cause catastrophic blood loss
Slide64EP risk factorsWhat are they?
Slide65PIDAssisted conceptionPelvic (especially tubal) surgeryPrevious ectopicSmokingCopper coil
Slide66EPAbnormal vaginal bleeding, abdominal pain or collapse in a woman of reproductive age? Always rule out ectopic!The classical presentation is collapse with abdominal pain – although this occurs <¼ of the time
Slide67Symptoms of an Ectopic PregnancyLight vaginal bleeding (scanty, dark bleeding)Nausea and vomiting with pain.Lower abdominal pain.
Sharp abdominal cramps.Pain on one side of your body (
differential is appendicitis)Dizziness or weakness.Pain in your shoulder, neck, or rectum.If the fallopian tube ruptures, the pain and bleeding could be severe enough to cause fainting.
Slide68Examination findings?
Slide69EPTachycardia (blood loss) – although hypotension and collapse only occurs in severe blood lossAbdominal and rebound tendernessCervical excitation (pain on manipulation of uterus)Adnexal tendernessSmall uterus for gestational ageCervical os closed
Slide70EPInvestigations?
Slide71EPPREGNANCY TEST! (Any woman of reproductive age with collapse, abdo pain or bleeding)TVUSS (can see intrauterine pregnancies)A hCG level that is rising by less than 66% over 48 hours means it is likely, but not a certainty, that the pregnancy is ectopicLaproscopy
Slide72EPManagement for EP varies depending on the patientAcute presentations (patient is haemodynamically unstable) and subacute presentationsName 3 TREATMENT options
Management: Pregnancy test, IV access, FBC and cross match, USS, nil by mouth,
laproscopy or medical management
Slide73Salpingectomy (removal of whole tube)Salpingostomy (removal of ectopic from tube)Methotrexate (25% need another dose or surgery)Note that to use methotrexate (medical management) 3 criteria are required:
Unruptured ectopic
No cardiac activityhCG <3000 IU/mL
Slide74EPRisk of another EP?Chance of subsequent successful pregnancy?
Slide7510%70%
Slide76Summary EPEmbryo implants where is shouldn’tCommon (1-2%)Abdo pain, bleeding and collapse required pregnancy test!Key invs: hCG, TVUSS, laproscopyTreatment: salpingectomy,
salpinostomy, methotrexate
Slide77Molar pregnanciesDecided not to cover because of timeGestational trophoblastic disease is RARE but Sheffield is a key centre so you never know what might come up in the exam… Might be worth a lookBuzzword: “Snowstorm” appearance on ultrasound scan!
Slide78Hypertensive Disorders in PregnancyWhat is pregnancy induced hypertension?What is chronic/pre-existing HTN?What is pre-eclampsia?
Slide79BP rises above 140/90 AFTER 20 weeksBP above 140/90 BEFORE 20 weeks or is on antihypertensive medicationHypertension (pregnancy-induced) and proteinuria (>0.3g/24h) in 2nd half of pregnancy
Slide80Pre-eclampsiaMild: proteinuria with mild/moderate HTNModerate: proteinuria with severe HTNSevere: proteinuria with HTN <34w or with maternal complicationsN.B. Mild HTN 140/90 – 149-99; moderate 150/100-159/109 and severe >160/110
Slide81PathophysiologyIncomplete trophoblastic invasion and acute artherosis (foam cells in spiral arteries)… Ischaemic placenta… leads to exaggerated, widespread inflammatory reaction in mum
Endothelial cell damage
(clotting problems)Vasoconstriction Increased vascular permeabilityOedemaProteinuria
Hypertension
Eclampsia
Liver damage
Slide82Pre-EWhat are the risk factors for pre-eclampsia?
Slide83PROF CANT DOPersonal HxRenal diseaseOlderFHChronic HTNAI Disease (APS)NulliparityTwin pregnancies
DiabetesObesity
There is NO cure for pre-e: prof can’t do anything!
Slide84How do you assess urinary protein?
Slide85Protein: creatinine ratio (PCR) - >30mg/nmolDipstick 24 hour collection
Slide86History from mumPatient is usually asymptomatic apart from at a late stage:Headaches, drowsiness, visual disturbancesNausea, vomiting, epigastic painSwelling due to oedema
Slide87What are the maternal complications of pre-eclampsia?
Slide88DEATHEclampsia CVAHELLP Syndrome DICLiver failureRenal failurePulmonary oedema (Tx oxygen and furosemide)
Slide89What is HELLP Syndrome?What types of seizures do you get in eclampsia and what is the treatment?
Slide90H: haemolysis (dark urine, raised LDH, anaemia)EL: elevated liver enzymes (epigastric pain [bad sign!], liver failure, abnormal clotting)LP: low platelets (self-limiting)Might also get DIC, liver failure or liver rupture
Slide91Tx of EclampsiaGeneralized tonic-clonicThis is thought to be due to cerebrovascular vasospamMagnesium sulphate – not an anticonvulsant but it increases cerebral blood flowMost epilepsy medication is related to fetal complications
Slide92What are the fetal complications of pre-eclampsia?
Slide93Fetal complications of Pre-EDEATH (5% of still births attributable to Pre-E)IUGRPre-term birth (10% accounted for by Pre-E)Placental abruptionHypoxia
Slide94InvestigationsUrinary protein (exclude infection if raised)Blood tests – low platelets (get help as HELLP is on the way!)LDH – up in heamolysis and liver diseaseLFT – high ALT suggests HELLP or liver diseaseUmbilical artery doppler to observe fetal blood flow
Slide95Starting treatment with what at <16w is recommended by NICE for high risk women?
Slide96Aspirin 75mg
Slide97ManagementAdmission to hospital is required for severe HTN or proteinuriaAnti-hypertensives are started if BP reaches 150/100 and started urgently if BP is >160/110If BP is >150/100 but <160/100 – what is the drug used to treated this and what class of drug is it?If HTN is severe, what are the 2 treatments required?Also if patient is diagnosed <34 weeks – give steroids
Slide98Labetalol, beta-blockerOral nefidipine – 1st (dihydropyridine calcium channel blocker) then consider IV labetalol
Slide99When to deliver if:Mild pre-eModerate pre-eSevere pre-eSevere pre-e with maternal complications or fetal distress
Slide100By 37 weeks34-3634-36NOW regardless of gestationBefore 34 weeks c/s – after the mother can be induced using prostaglandins
Slide101Antepartum haemorrhageDefinition?Causes?
Slide102Bleeding from the genital tract after 24 weeks gestationCommon: undetermined origin, placenta praevia, placental abruption Uncommon: incidental pathology, uterine rupute
, vasa praevia
Slide103Placenta PraeviaWhat is it?How common is it at term?Types of PP?
Slide104Placenta is implanted into the lower segment of the uterus0.4% of pregnancies at termMarginal – low lying by not covering osMajor – placenta covers some or all of os
Slide105Slide106Risk factors?
Slide107Previous caesarian section (placenta implants into c/s scar)TwinsHigh parityOlder
Slide108Complications?
Slide109Placenta accreta, placenta increta, placenta percretaMassive haemorrhage so large mother may need hysterectomyC/sTransverse lie, breech presentation
Slide110Clinical featuresWhat might the mother give as a hx?What examination should NEVER BE PERFORMED?
Slide111Intermittent, painless bleeds which increase in frequency and intensity over several weeksHowever, 1/3 experience no bleeding before birthVaginal examination
Slide112How is the diagnosis made?
Slide113USSBefore 20 weeks placenta can be ‘low-lying’ but 90% of these do not develop in placenta praeviaIf a low-lying placenta is seen at the 20 week USS, a repeat USS is done at 32 weeks. If it’s within 2cm of the os, it’s likely to be PP at termAnterior placentas seen at 20 weeks can be scanned using a 3D power USS to check for placenta
accreta
Slide114When to admit:Any pregnant woman with bleeding should be admitted – if PP found, they stay in hospital until delivery as there’s a risk of massive haemorrhageBloods, IV access, anti-D to rh-ve women, steroids <34wPP and asymptomatic? Mum can stay at home until 37 weeks providing they can get into hospital easily
Slide115When to deliver?
Slide11639 weeks by most senior person availableBe prepared for placenta accreta or percreta!Be prepared to PPH
Slide117Placental abruptionWhat is it?How common is it?
Slide118It’s when the placenta separates before the delivery of the fetus1%When the placenta separates, there can be significant maternal bleeding behind it
Slide119Blood can track between the membranes and myometrium to reveal APHOr blood can go directly into the myometrium (‘concealed’)Visible haemorrhage is absent in 20% of cases!
Slide120Slide121Complications?
Slide122Fetal death (30%!)Maternal death (rare)Haemorrhage transfusion requiredHaemorrhage DIC and renal failure
Slide123Risk factors?
Slide124Previous PAIUGRPre-eclampsiaPre-existing HTNSmokingCocaineAI diseaseMultiple pregnancyHigh maternal parityAnd more….
Slide125Clinical features?
Slide126SymptomsPainBleeding (dark)Pain can occur alone with concealed blood lossVisible bleeding does not equate to severity of abruption
Slide127SignsBuzzword: woody hard uterus on examinationTender, contracting uterusTachycardiaHypotension with severe loss of blood – this can lead to maternal collapseFetal heart tones abnormal or absentPoor urine outputRenal failure
Slide128A woman, 32 weeks pregnant, comes into A+E with pain and uterine tenderness but no bleedingWhat should you do?
Slide129Admit! Even without bleeding, pain and uterine tenderness is a reason to admitIV fluidsOpiate analgesiaSteroids (<34 weeks)Anti-D to rh-ve womenMonitor U+Es for renal problemsCTG for fetus
Slide130DeliveryFetal distress? Deliver urgently via c/sNo fetal distress but gestation >37 weeks? Induce with amniotomyNo fetal distress and <37 weeks? Steroids if <34 and monitor Fetus dead? Coagulopathy is likely to occur so induce labour and get blood products ready
Slide131PAPP
ShockInconsistent with external loss
Consistent with external lossPainCommon, often severeNoBleedingMaybeDarkYesRed and profuseTendernessCommonWoody hard uterusRareFetusLie usually normalFetus distressed or deadLie often abnormalFetal HR often normalUSSOften normalLow placenta
Slide132QuestionsA 39 year old primigravid woman who has had no antenatal care attends a labour ward at 39 weeks gestation. She complains of heavy, unprovoked, painless vaginal bleeding. On examindation she has a soft, non-tender abdomen and the head is not engaged. She is passing clots per vagina. HR 112 BP 96/56. CTG non reassuring.
What is the most likely diagnosis?Cervical ectropion
Placental abruptionPlacental praeviaUterine ruptureVasa praevia
Slide133B – placenta praevia
Slide134A 31 year old woman, who has recently had a postive pregnancy test, has an early TVUSS which showed no intrauterine pregnancy. She subsequently has two beta hCG samples taken, the first one the day of the scan and the second 48 hours later. The first test result was 578iu and the second 1126iu. What is the most likely diagnosis?Ectopic pregnancy
Early intrauterine pregnancyInevitable miscarriage
Missed miscarriageThreatened miscarriage?
Slide135Answer – B: early intrauterine pregnancyThe fact that beta hCG was less than 1000 iu on the day of the scan explains why no pregnancy was seen. >1000 iu usually means the gestational sac can be seen. If the repeat hCG is static or only reducing slowly, an ectopic must be ruled out and further management considered.
A SIGNIFICANT fall in bHCG is caused by a miscarriage
An empty uterus means 3 things: ectopic pregnancy, early intrauterine pregnancy or missed miscarriage.
Slide136A 25 year old woman is brought into the resus area having collapsed. She is maintaining her airway and is breathing via a non-rebreathe bag. She has a week pulse, HR 123, BP 86/48, o2 98%, temp 37.2. After fluid resuscitation the patient is responsive enough to tell you she had some lower, right sided abdominal pain earlier in the day but cannot remember anything else. She uses the copper coil for contraception. On examination, she is tender with guarding in the right iliac fossa. On speculum examination there is brown discharge seen in the vagina. Threads for the coil are seen and cervical excitation is present. A urine result is awaited. What is the most likely diagnosis?Appendicitis
Dislodged coil to the cervical locationEctopic pregnancy
Ovarian cyst torsionPID
Slide137C – ectopic pregnancyThis is the most likely to be an ectopic pregnancy which may have ruptured into the abdominal cavity leading to the patient become clinically shocked.
Slide138A 30 year old primigravid woman who is 34 weeks pregnant attends the antenatal clinic. She has persistent hypertension of 164/112 mmHg and some protein in her urine on dipstick testing. She has no visual disturbance, no epigastric pain and complains of mild headaches which are generally relieved by paracetamol. On examination her abdomen is soft non-tender, she has mild petal oedema, normal reflexes and one beat of clonus. Her bloods are normal. She has asthma for which she takes a salbutamol inhaler when required. What hypertensive should you use to manage her?
A) furosemideB) labetalol
C) magnesium sulphateD) nefidipineE) rampril
Slide139D - nefidipine