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Antenatal care
Booking Investigations
Each visit
BP
Dip urine
Fundal height (1 cm/week)
Fetal heart with Doptone
Palpate abdomen for
presentation/station
Screening
Labour
Primiparous- 12-24 hrs
Multiparous- 6-12 hrs
Usually defined as the onset of
painful, regular contractions, more
than one every ten minutes, with
progressive cervical effacement and
dilatation accompanied by descent of
the presenting part.
Initiation
Physiological factors largely
unknown.
Occurs when factors which inhibit
contractions and maintain a closed
cervix diminish and are succeeded
by the actions of factors which do the
opposite.
Increase in intracellular free calcium
brings about contraction.
Prostaglandins and oxytocin increase
Stages in Labour
Stage I- Onset of labour to full
dilatation. latent and active phase
(>3cm dilated.)
Stage II- Full dilatation to delivery of
baby (<4hrs in prim, <3hrs in Multi)
Passive and active.
Stage III- Birth of baby to delivery of
placenta. (<1hr) Can be active
(Syntocinon/Syntometrine) or
Physiological.
Progress
Confirm presentation
Monitor FH -Intermittent/ Continuous
Uterine muscle Contractions- 3-5
good contractions in 10 mins.
Examine for Cx dilatation/
effacement/ station and position
every 4hrs. Expect minimum
progress 0.5-1cm/hr.
Progress
Confirm presentation
Monitor FH -Intermittent/ Continuous
Uterine muscle Contractions- 3-5
good contractions in 10 mins.
Examine for Cx dilatation/
effacement/ station and position
every 4hrs. Expect minimum
progress 0.5-1cm/hr.
Partogram
Fetal Monitoring.
Presentation
Station
Position
Related to OCCIPUT (posterior
Symphysis Pubis
fontanelle)
Direct
L
R
Right
ANTERIOR
TRANSVERSE
TRANSVERSE
R
Left
POSTERIO
R
Direct
Sacrum
Position
Related to OCCIPUT (posterior
fontanelle)
Symphysis Pubis
Direct
L
R
Right
ANTERIOR
TRANSVERSE
TRANSVERSE
R
Left
POSTERIO
R
Direct
Sacrum
Analgesia in labour
Breathing/ TENS/ Bath/ Co-codamol
Entonox (Nitrous oxide/ oxygen)
Morphine- can cause CTG changes/
neonatal resp depression.
Remifentanyl PCA.
Epidural- L3/4 ( Needs IV fluids,
Catheter, Continuous CTG)
Can be topped up if needs LUSCS.
Problems.
Types of delivery
SVD
Assisted delivery
Vaginal breech delivery.
LUSCS (lower uterine segment
caesarean section)
SVD
Engagement
Descent
Internal rotation
Crowning/Extension
Restitution
Delivery of ant then
post shoulder.
Third stage
Delivery of placenta.
Controlled cord traction.
Guard uters.
Syntocinon/ Syntometrine.
Risk of PPH
Emergencies
Malpresentation- Breech, face, Brow,
compound- LUSCS.
Cord prolapse- Cord comes out with
fluid. Elevate presenting part- Crash
LUSCS
Shoulder dystocia- Head delivered.
Shoulders stuck. Manoeuvres to try
disimpact.
The puerperium
Breast feeding
Oestrogen and Progesterone
Breast feeding
Breast feeding
Skin to skin contact/ Bonding
Receives all required nutrients
Passive immunity of antibodies
Cant breast feed with certain
medications or if HIV +ve
Complications
Cracked nipples
Mastitis
Milk stasis
Poor supplyDomperidone
Definition
Onset of labour before 37 weeks
Presence of uterine contractions of
Risk Factors
Social factors
-
Fetal anomaly
Risk Factor
Uterine anomaly
- congenital
- cervical incompetence
Infection
-maternal pyrexial illness
-chorio-amnionitis (caused by premature rupture of
membranes)
Trauma
-injury
-surgery during pregnancy
Drug treatment
DHP Calcium channel blockers
(nifedipine)
Inhibit uterine muscle contraction
No proven benefit over
betamimetics, other than fewer side
effects
Dose of 20mg given followed by 1020mg given 3-4times daily
depending on uterine activity
Tocolysis
Oxytocin receptor antagonist
(atosiban)
Blocks action of oxytocin on uterus
which stimulates contractions
Given IV, maximum duration 48hours
Licensed for inhibition of premature
labour between 24 and 33 weeks
gestation
POST PARTUM
HAEMORRHAGE
PPH
>500mls blood loss PV
Primary or secondary
Secondary- endometritis/RPOC
Primary PPH
Emergency
ABC
A- talk to pt
B- facial O2
C- IV Access (2 large venflons)
FBC, Coag, X-match
IV fluids
Causes
T- Tone
T- Tissue
T- Trauma
T- Thrombin
Tone
Bimanual compression
Tissue
Check placenta
Manual removal
Trauma
Genital tract trauma
Repair
Thrombin
ANTE PARTUM
HAEMORRHAGE
APH
Bleeding from the genital tract after
24 wks gestation
2-5% of pregnancies
Important cause of maternal and
fetal morbidity and mortality
Causes
Placenta praevia
Placental abruption
Show
Local causes
Vasa praevia
Placenta praevia
Placenta develops in lower uterine
segment. 0.5% of all pregnancies
Risk factors- increased age
-multiparous
- prev LUSCS
- Smoking
- prev history
- multiple pregnancy
Classification
Presentation
20 wk USS (97% will migrate)
Painless vaginal bleedingunprovoked
Post coital bleeding
Malpresentation
Diagnosis
VE/ Speculum should not be carried
out if PP suspected
USS (TV scan best)
MRI scanning can
help detect accreta
Management (Major)
If symptomatic- admit
Large cannula, G&S
Delivery at 37-38wks by LUSCS
(earlier if indicated)
Best to have blood, cell salvage and
interventional radiology ready
Placental Abruption
Bleeding following separation of
normally sited placenta. 0.5-1.5% of
all pregnancies
Risk factors- Increased age
- Multiparous
- Smoking
- Recreational drug use
- Abdominal trauma
Classification
Revealed/
Concealed
Presentation
PV bleeding- Amount may not
correlate with significance of
haemorrhage
Abdominal pain/ tension
Shock/ collapse
Fetal distress
Diagnosis
Usually clinical
USS (only
if mother
and baby
stable)
Management
ABC
Resuscitation
Delivery if required
Increased risk of PPH
Watch for signs of DIC
MISCARRIAG
E
Miscarriage
Threatened miscarriage
Inevitable miscarriage
Heavy PV bleeding and pain
Open cervix
Products in canal
Complete/ Incomplete
Complete- products passed and
uterus empty
Missed miscarriage
Pregnancy Loss with no sx
Can be picked up at booking scan
Pregnancy sx usually gone away
Management
Expectant- Await body to pass
pregnancy
Surgical- Evac
MVA manual vacuum aspiration
Medical- Mifepristone and Misoprostol
Recurrent miscarriage
3 or more miscarriages
1% of all women
Chromosomal abnormality
Congenital uterine abnormalities
Cervical incompetence
Infection
PCOS
Thrombophillia
Molar pregnancy
High HCG, Large uterus
PV Bleeding
PARTIALMOLE
Molar pregnancy
COMPLETEMOLE
Whole placenta is abnormal and
grows rapidly. No developing fetus.
One sperm enters the egg but only
half of one set of chromosomes are
present. Aneuploid.
Diagnosed on USS
Snow storm
appearance
Management
Surgical evac
Products sent to lab for conformation
Register with Molar pregnancy unit
(Dundee)- They will follow up
Track HCG to 0
No new pregnancy for 1 yr but need
to avoid combined hormonal
contraception
MULTIPLE
PREGNANCY
Multiple pregnancy
Incidence of twins ~1/100
Triplets ~1/4000
Predisposing factors Increased age
-Family/personal
Hx
- Fertility
treatment
-Race
Terms
Mono/Dizygotic- No. of embryos
Chorionicity- No. of placentas
Amnionicity- No. of amniotic sacs
Dizygotic twins
Non identical
2 embryos implant
Always 2 placentas and 2 sacs
Monozygotic twins
Identical
1 embryo splits
Split <3 days- DCDA
4-7 days- MCDA
8-12 days- MCMA- rare
13-15 days - conjoined twins
Diagnosis
Booking scan
Before if hyperemesis/ fertility Rx
Antenatal complications
FETAL
Increased pre-term delivery and
sequalae
Increased risk of anomalies
Increased risk IUGR/IUD
Antenatal complications
MATERNAL
Severe hyperemesis
Increase risk miscarriage
Increase risk of anaemia, Preeclampsia, Pelvic pain, APH,
Placental praevia, Gestational
diabetes and PPH.
Cord accidents
Antenatal care
High Risk
More visits
Anomaly scan at 18-20 wks. (cant
really do CUBS/AFP)
Iron tablets
Serial Growth scans
Delivery ~38wks
Delivery
Vaginal vs LUSCS
If twin I is Breech or significantly
smaller- LUSCS
If twin I is cephalic- could try Vaginal
delivery
Continuous monitoring (FSE on twin
I)
IV access
Difficulty is with twin II- Should be 60
mins after I at most
TTTS
Treatment
Risky
Laser ablation of anastomosis
vessels
Early delivery
Constitutionally small
Small mother
Symmetrically small.
Less that 10th centile but growing
appropriately
Normal liquor volume
Normal umbilical artery dopplers
IUGR
Asymmetrical growth
Low liquor volumes/ Abnormal
Dopplers
Not growing along centiles
Sometimes fetal distress
Causes
Placental insufficiency
Fetal anomalies
Drugs
Infection
Placental insufficiency
Most Common
Abnormalities in placental
development
Diabetes
Pre-eclampsia
Thrombophilia
Connective tissue diseases
Placental infarction/abruption
Drugs
Management
Increased monitoring
Growth scans, liquor volumes and
umbilical artery dopplers every 2
weeks
Early delivery
Pre- eclampsia
Increased BP and proteinuria +/- oedema
> 30 mmHg systolic or >15mmHg
Severe
Defined severe if:
3+ protein or more in urinalysis
BP >170/110
Visual disturbances/headache/ papilloedema
RUQ/Epigastric pain/tenderness
Clonus
Oliguria/ Renal failure
HELLP syndrome (Haemolysis, Elevated Liver
enzymes, Low Platelets)
All above suggest eclampsia could be imminent.
Aetiology
Largely unknown
Immunological disturbance decreased
Risk factors
Primigravida
<20yrs age and >35yrs age.
Family/ Personal history of Pre
eclamsia
Multiple pregnancy
Obesity
Non smokers
Pre-existing hypertension or renal
disease
Risks to mother
Renal/Hepatic failure
HELLP
Stroke
Disseminated intravascular
coagulopathy (DIC)
Pulmonary oedema
Convulsions
Death
Risks to baby
Investigations
History
Exam (inc ando exam, reflexes,
fundoscopy)
Dip urine, regular BPs
Bloods (Large cannula, FBC, LFTs Urate,
U&Es, Coag and Grp and save)
If severe- Urinary catheter- monitor
output..
Invasive monitoring- central line,
ECG.
Treament
Treatment does not cure pre-eclampsia, its aim is
to prevent eclampsia
Only cure is to DELIVER BABY
Mild- Antihypertensives (Labetalol 200mg 3xday
or Methyldopa orally)
If <35wks gestation- steroids. 12mg
betamethasone IM.
Severe- IV Labetalol/hydralazine
- IV Magnesium sulphate 4g bolus and
1g/hr
Monitor BP, Urine output, Reflexes, Resp rate and
Mag levels if ? Toxicity
Cont..
CTG- for fetal wellbeing
Decide when safe to deliver baby. (can be
Future pregnancies.
Prophylaxis in future pregnancies
-Low dose aspirin (75mg)
Careful BP monitoring
Growth scans
Diabetes in
pregnancy
Diabetes
Pre existing Diabetes
Gestational Diabetes
Pregnancy is state of Insulin
resistance.
Placenta produces anti insulin
hormones (hPL, cortisol and
gulcagon)
Gestational Diabetes
Onset with pregnancy
Assess clinical risk and consider
abnormalities
Increases risk IUD/Neonatal death
Increased risk Pre-eclampsia
Polyhydramnios
Macrosomia/IUGR
Prematurity
Postnatal hypogycaemia and
Jaundice.
Antenatal care
Pre-conception counselling
Multi-disciplinary approach
Strict Diabetic control
Detailed Anomaly scan
ANC every 2 weeks at minimum with
growth scans
Induction at 38 wks
Labour
Continuous GTG
Sliding scale in certain cases- Half as
soon as placental delivered
6 wk follow up- GTT
BREAK
GYNAECOLOG
Y
Normal
Menstruation
Normal Menstruation
Normal cycle
Proliferative (Follicular)
phase
Day 5-13
Ovarian follicular growth
Increasing oestrogen
Growth and vascularisation of
endometrium
Ovulation occurs day 14
Ovulation occurs 14 days prior to
next period in a cycle that is not 28
days
Menstrual phase
Day 1-5
Decline of oestrogen and
progesterone
Breakdown of endometrium- sheds
Heavy
Menstrual
Bleeding
Causes
PALM COEIN
Polyp
Coagulopathy
Ademomyosis
Ovulatory
Dysfunction
Leiomyoma
Endometrial
Malignancy
Iatrogenic
Not yet classified
Assessment
History
Menstrual cycle length, duration
Heavy clots, flooding, tampons/pads
IMB, PCB
Associated pain
Examination
Abdominal
PV
Speculum- smear/swabs
Investigations
Pelvic USS
FBC, clotting, TFTs
In older women (>40yrs)
Pipelle biopsy
Hysteroscopy +/- biopsy
Causes
Fibroids (leiomyoma)
Benign tumours of myometrium
20% incidence in women >40yrs old
Management
Medical
Non-hormonal
Hormonal
Surgical
Minor
Major
Medical
Non- hormonal
Mefenamic acid (NSAID)
Tranexamic acid (antifibrinolytic)
Both taken during period only
Medical
Hormonal
Progestogens- Norethisterone
- Provera
- POP (Cerazette)
Mirena coil
COC, Depoprovera, GnRH analogues
Esmya
Radiological
Fibroids
Uterine artery embolisation
Requires MRI
Surgical (Minor)
Endometrial ablation
75% satisfied
Must have biopsy prior
to carrying out
Family should be complete
LASH alternative
Myomectomy (fibroids)
Surgical (Major)
Hysterectomy +/- BSO
Should not be considered unless tried
alternative treatment or has very
large fibroids
Endometriosis
Ectopic endometrial tissue
Usual sites:
Pouch of Douglas
Uterosacral ligaments
Ovarian fossae
Bladder
Within uterine muscle (adenomyosis)
Very rare: lungs, brain, muscle
Usually present with pain/infertillity
Graded I-IV
Treatment COCP, progesterones, GnRH, surgical
Urinary
Incontinance and
prolapse
Prolapse
Downward displacement- weakening of
support (pelvic floor)
Definitions
Uterovaginal
Grade I
Uterovaginal
Grade II
Uterovaginal
Grade III- complete eversion
Grade III
Procedentia
Ulceration
Rec
Sypmtoms
Treatment
Mild- Oestrogen cream
- Pelvic floor exercises
Pessaries
Urinary incontinence
Urge
Overactive bladder
Inability to delay following sensation to
void
e.g. Key in the door
Detrusor instability, neurogenic bladder,
infection
Stress
Loss of urine when intra-abdominal
pressure increased
Weak pelvic floor or sphincter
Treatments Urge
Treatments- Stress
Physio (PFE, Electrical stimulation of
muscles)
Urethral bulking
Sub-urethral sling (TVT-O)
Colposuspension
Gynaecological
cancers
Endometrial cancer
postmenopause
Pipelle biopsy
Hysteroscopy, D&C
Staging
Stage I
Confined to uterus
Stage Ia
No myometrial invasion
Stage Ib
Stage Ic
Stage II
Involvement of cervix
Stage III
Pelvic spread
Stage IV
Bladder/rectum/distant (lung)
Treatment
Hysterectomy
Pelvic clearance
omentectomy/appendicectomy
Chemotherapy/ Hormone therapy
(advanced)
Stage I
75%
5 yr survival
Stage II
58%
Stage III
30%
Stage IV
10%
Ovarian cancer
Most deadly
Peak age 68-85yrs old
90% sporadic, 10% genetic
Epithelial tumours 85%
Increased risk: Nulliparous, higher social
class, ovulation induction
Decreased risk- COC use
Ovarian tumour
Staging
Stage I -25%
Confined to ovaries
Stage Ia
One ovary
Stage Ib
Both ovaries
Stage Ic
Stage II -10%
Confined to pelvis
Stage IV -20%
Distant spread
Treatment
Pelvic clearance +
chemotherapy
Radiotherapy
5 yr survival
Stage I
67%
Stage II
51%
Stage III
20%
Stage IV
5%
Cervical cancer
Peak age 45-55 (can occur as young as 20)
Risks Defaulting smears
Multiple partners
HPV 16+18 (80-90%)
COC use
Smoking
Cervical screening
Cervical smear
Pre-cancerous changes
Transformation
zone
Dyskaryosis
Cervical
intraepithelial
neoplasia (CIN)
May persist for
years
Can revert to
normal
30% CIN 3 will
Cervical cancer
Staging
Stage Ia
Stage Ib
Confined to Cx
Stage II
Stage III
Stage IV
Treatment
Hysterectomy
Radical
Radiotherapy
Chemotherapy
5yr survival
Stage I
80%
Stage II
61%
Stage III
32%
Stage IV
15%
Vaccination
Gardasil
Protects against HPV 16 & 18, 6 & 11
99% effective
Girls age 12-13 yrs old
Will still need smears as rare Cx
cancers and current population not
protected.
Vulval cancer
Least common
Peak age 65-70 yrs old
Squamous carcinoma 92%
Risks- HSV
HPV (16/18)
Smoking
Immunosuppresion
VIN
Vulval cancer
Staging
Stage I
Stage II
Stage III
Stage IV
Treatment
Stages I-III Radical
vulvectomy
Radiotherapy/
Chemotherapy
Stage IV- Palliative
only
5 yr survival
Stage I
97%
Stage II
85%
Stage III
74%
Strage IV
30%
PCOS
Varying degrees
Unknown aetiology
Clinical signs- Oligomenorrhoea
- Obesity
- Hirsutism
Endocrine measurements
Increased LH/ Low FSH---> increased
LH:FSH ratio
Increased testosterone
Decreased SHBG
Insulin resistance and impaired glucose
tolerance. (11%)
Moderate hyperprolactinaemiaoccasionally
USS assessment
Increased ovarian volume
10-15 microcysts <10mm in diameter
String of pearls
PCOS
PCOS
Diagnosis can be made if has 2 of 3:
Clinical features
Endocrine findings
USS findings
Treatment
Weight loss
Metformin
Laser Rx for hirsuitism
COC, Mirena, Depo provera
Fertility Rx with clomid
Ectopic
pregnancy
Ectopic pregnancy
Implantation outside uterus
1.2% of pregnancies
Incidence rising
Tubal -97%
Cervix
Ovary
Peritoneum
Abdominal
Risk factors
STI/PID
IUD/Mirena
Previous Ectopic
Sterilisation/ Tubal Surgery
Assisted reproduction
Presentation
Diagnosis
Clinical (peritonism, adnexal mass,
unstable)
Serum HCG tracking
TV USS (no IU pregnancy, adnexal mass,
free fluid)
Laparoscopy
TV USS
Management
Surgical
Laparoscopic
Salpingectomy
Any signs of
rupture
Laparotomy
Check other tube
is not damaged
Medical
Methotrexate- 50mg/m2
Must fit criteria and be
compliant to follow up
Check U&Es and LFTs
HCG tracking- may initially
rise
5-10% require surgery
No pregnancy for 3 months
Avoid alcohol/ sunlight
Conservative
Risky
Must be asymptomatic and stable
Falling HCG
Track to zero
pregnancy
Subsequent pregnancies 10-15% will be
ectopic
Early Ultrasound