Summary of obstetric conditions and complications as covered in zero to finals. Contains information about clinical features of each condition, as well as relevant diagnostic tests and investigations, risk factors, causes and management guidelines.
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Early pregnancy
1. Ectopic pregnancy
2. Miscarriage
3. Molar pregnancies
4. Nausea and vomiting
5. Recurrent miscarriage
6. TOP
Antenatal care
1. Pregnancy timeline and booking clinic
2. Trisomy 21 screening
3. Chronic conditions in pregnancy
4. Infections in pregnancy
5. Medications in pregnancy
6. Acute fatty liver of pregnancy
7. Anaemia
8. Breech presentation
9. Cardiac arrest in pregnancy
10. Gestational diabetes
11. Large for gestational age
12. Multiple pregnancy
13. Obstetric cholestasis
14. Placental abruption
15. Placenta accrete
16. Placenta praevia
17. Pre-eclampsia
18. Rashes of pregnancy
19. Small for gestational age
20. Stillbirth
21. UTIs in pregnancy
22. Vasa praevia
23. VTE in pregnancy
Labour and Delivery
1. Labour
2. Cardiotocography
3. Drugs in labour
4. Failure to progress
5. Induction of labour
6. Pain relief
7. Premature labour
8. Umbilical cord prolapse
,ECTOPIC PREGNANCY
CLINICAL SIGNS PATHOPHYSIOLOGY
Presents around 6-8 weeks gestation – should Pregnancy implanted outside the uterus – most
have low threshold for suspicion commonly in the Fallopian tube
- Missed period Other locations: entrance to the fallopian tube, ovary,
- Constant lower abdo pain in RIF/LIF cervix, abdomen
- PV bleed Incidence 11/1000
- Lower abdo or pelvic tenderness
- Cervical motion tenderness
May have
- Dizziness or syncope (blood loss) RISK FACTORS
- Shoulder tip pain (peritonitis) Previous ectopic
Previous PID
Previous surgery to fallopian tubes
IUD
INVESTIGATIONS
Older age
Transvaginal USS IVF
- May see gestational sac in fallopian tube Endometriosis
- ‘blob sign’ or ‘bagel sign’ Smoking
- Tubal ectopic pregnancy moves separately
to the ovary (in contrast to corpus luteum)
- Empty uterus
- ‘Pseudogestational sac’ CRITERIA FOR EXPECTANT MANAGEMENT
Positive pregnancy test + no evidence of Follow-up possible to ensure successful
pregnancy on USS termination
Ectopic must be unruptured
- Serial hCG: Rise < 63% after 48 hours Adnexal mass < 35mm
likely to indicate ectopic pregnancy (needs No visible heartbeat
close monitoring) No significant pain
- Fall > 50% likely to indicate miscarriage HCG < 1500IU/L
(urine pregnancy test 2/52 to confirm
complete)
MANAGEMENT
1. Expectant management
2. Methotrexate
3. Surgical management
Methotrexate - criteria same as expectant management + HCG < 5000IU/L, confirmed absence of
intrauterine pregnancy on USS
Highly teratogenic – given as IM injection. Women advised to not get pregnant for 3/12 following
treatment
Common AEs: PV bleed, N+V, Abdo pain, stomatitis (inflammation of mouth)
Surgical – salpingectomy (1st line), salpingotomy
Indications: pain, adnexal mass > 35mm, visible heartbeat, HCG > 5000IU/L
Salpingotomy may be used in women at increased risk of infertility due to damage to the other tube.
Increased risk of failure compared to salpingectomy – may need further treatment with methotrexate
Anti-D prophylaxis given to rhesus negative wome having surgical management
, MISCARRIAGE
SUMMARY DEFINITIONS
Occurs in ~20% of pregnancies – highest early in Early miscarriage < 12 weeks
pregnancy Late miscarriage 12-24 weeks
Incidence increases with maternal age - Missed miscarriage – fetus no longer alive, no
symptoms have occurred
- Threatened miscarriage – PV bleed with closed
PRESENTATION cervix and fetus is alive
Usually hx of PV bleed and lower abdomen - Inevitable miscarriage – PV bleed with open
pain cervix
Passage of tissue may be reported - Incomplete miscarriage – retained POC in
Bleed can vary from life-threatening to utero
spotting - Complete miscarriage – full miscarriage has
occurred, no POC left in uterus
- Anembryonic pregnancy – gestational sac
present but no embryo
INVESTIGATIONS
Transvaginal USS MANAGEMENT < 6 WEEKS GESTATION
Mean gestational sac diameter Expectant given no pain or other complications
- Fetal pole is expected once gestational sac including risk factors (e.g. previous ectopic)
is > 25mm Repeat urine pregnancy test is performed after 7-10
- If > 25mm and no fetal pole the scan is days and if negative a miscarriage can be confirmed
repeated after 1 week before confirming
anembryonic pregnancy If bleeding continues or pain occurs referral and
further investigation may be indicated
Fetal pole and crown-rump length
- CR length < 7mm without fetal heartbeat
the scan is repeated after at least 1/52 to
INCOMPLETE MSICARRIAGE
ensure heartbeat develops
- CR length > 7mm without fetal heartbeat Retained POC create risk of infection
scan is repeated after 1/52 to confirm non- - Medical management – misoprostol
viable pregnancy - Surgical (GA)
Fetal heartbeat o Retained POC removed using vacuum
aspiration and curettage
- Visible = viable
o Key complication = endometritis
- Expected once CR length is > 7mm
Remember to exclude ectopic pregnancy – serial
HCG may be helpful
MANAGEMENT
Transvaginal USS to confirm location and viability
Expectant (1st line for women without risk factors for heavy bleeding or infection). 1-2/52 to allow
miscarriage to occur spontaneously
Repeat urine pregnancy test after 3/52 to confirm miscarriage complete
Misoprostol – PG analogue to soften cervix and stimulate uterine contractions. It is taken as oral dose or
vaginal suppository
AEs: heavier bleeding, pain, vomiting, diarrhoea
Surgical management
- Manual vacuum aspiration under LA
o < 10 weeks gestation
o More appropriate for parous women
o Syringe inserted into uterus and contents manually aspirated
- Electric vacuum aspiration under GA
o Cervix gradually widened using dilators and POC removed using electric-powered vacuum
- Misoprostol given prior to surgery
- Anti-rhesus D prophylaxis given to rhesus negative women having surgical management
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