phase 3a louise & alys the peer teaching society is not liable for false or misleading...

Phase 3a

Louise & Alys

Obs & Gynae

The Peer Teaching Society is not liable for false or misleading information…

• Antenatal Screening• Hyperemesis• Miscarriage• Ectopic Pregnancy• Molar Pregnancy • Pre - eclampsia


Aims


Antenatal Screening

• Detect Disease in the mother• Prevent or detect and manage maternal

complications• Prevent or detect foetal complications• Detect congenital foetal problems if requested

by patient


Q – Why do we screen in pregnancy?

• BP• BMI • FBC• Serum antibodies (anti-d)• BM• Syphilis • Rubella immunity• HIV• Hep B and C • Urine dip


Q- What investigations are done at the booking visit?

• Those with an at risk Hx– Hx of GDM– 1st degree relative with diabetes– Previous unexplained stillbirth– Previous macrosomic infant (BW >4kg)– Maternal BMI >30– Repeated episodes of glycosuria– Maternal age >35yrs– PCOS


Q- Who should be screened for Gestational diabetes?

• Presence of foetus and no. of foetuses• Heartbeat• Crown Rump Length • Foetal nuchal translucency• Check ovaries


Q - What do they look for at first scan?

• Confirm viability of foetus• Foetal measurements: Foetal head size,

abdominal circumference, biparietal diameter, femur length

• Detect structural abnormalities – e.g. anencephaly, spina bifida

• Internal structure abnormalities – e.g. heart disease, diaphragmatic hernia

• Amniotic fluid volume


Q -What do they look for at the 2nd scan?

• Combined test (11-14 wks):• Nuchal translucency + PAPP-A + β-HCG

• Quadruple test (14-20wks):– AFP– Inhibin A– Oestrodiol– β-HCG


Q- What are the types of Down’s screening?

• Amniocentesis:– Can detect Neural tube defects and chromosomal

disorders– Takes 3 weeks for karyotyping– 1% foetal loss rate

• Chorionic Villous Sampling:– Can be used up to 20 wks– Doesn’t detect NTD – Placental sample– Quicker result (2 days for karyotyping)– 4% foetal loss rate


Amniocentesis and CVS

• Persistent pregnancy related vomiting associated with weight loss of >5% of body mass, dehydrations and ketosis.

• Begins between 4-10 wks, ends before 20wks


Hyperemesis Gravidarum

• Idiopathic• Multiparous• Multiple pregnancy• Hyatidiform mole• Hx of Hyperemesis Gravidarum• H. pylori infection


Q – what are predisposing factors of Hyperemesis Gravidarum?

• Dehydration– Tachycardia– Hypotension

• Electrolyte imbalance

–HYPOCHLORAEMIC ALKALOSIS• Thiamine deficiency


Q - What are the complications?

• Exclude other causes of vomiting • Urine Dip for ketones, blood and proteins and send

for cultures• FBC• U&Es• LFTs• TFTs• Blood Gasses• USS


Investigations

• IV fluids – correct hypovolaemia and electrolte imbalance

• Antiemetics e.g. cyclizine and metoclopramide• THIAMINE • Thromboprophylaxis – compression stockings

and consider LMWH


Management

• Pregnancy loss <24 weeks gestation• 15% pregnancies


MISCARRIAGE

• Most are idiopathic• Chromosomal abnormality • PCOS• Advanced maternal age• Maternal lifestyle

– Smoking, obesisty, alcohol, caffeine, cocaine, cannabis, stress• Uterine abnormalities• Cervical incompetence • Infection• Antiphospholipid syndrome• Thrombophylic defects


Q – What are some causes of miscarriage?

• Threatened miscarriage

• Inevitable miscarriage

• Incomplete miscarriage

• Complete miscarriage

• Missed miscarriage

• Septic miscarriage


Types of Miscarriage

• Threatened miscarriage – Bleeding, uterus enlarged, foetus alive, os closed– 25% go on to miscarry

• Inevitable miscarriage– Heavier bleeding, os open, miscarriage will happen

• Incomplete miscarriage– Pain develops, os open, some parts passed, some retained

• Complete miscarriage– All foetal tissue passed, uterus not enlarged, os closed, bleeding subsides

• Missed miscarriage– Empty gestational sac on USS, uterus smaller than expected and os closed,

can be asymptomic

• Septic miscarriage– Contents of uterus are infected, shock can develop


• Urine dip – pregnancy test• USS • FBC and Rhesus group• Expectant management • Medical management – MISOPROSTOL

Surgical management – ERPC


Management

• Any pregnancy occuring outside of the uterine cavity

• Most common site is the Fallopian tube• 1% of all pregnancies


Ectopic Pregnancy

• Idiopathic• Hx of ectopics• Hx of chlamydia• PID• Subfertility• Pregnancy that happens despite the presence

of an IUD


Q – What are some predisposing factors?

• Amenorrhoea of 4-10 wks • Lower abdo pain followed by dark vaginal bleeding (+/- clots)• Pain is initially colicky and then constant• Can mimic appendicitis • Subdiaphragmatic irritation causes referred shoulder-tip pain• Collapse (<25%)• Signs on examination:

– Signs of shock – hypotension and tachycardia– Peritonism – abdo distension, guarding, rebound tenderness– Cervical excitation – Adnexal tenderness


Q – What is the clinical presentation?

• Diagnosis:– Urine pregnancy test + USS– Serum hCG– FBC– Cross match blood– Give patient anti-D if Rh -ve

• Management:– Medical – Methotrexate– Surgical – Salpingotomy or salpingectomy


Diagnosis and management

• Abnormality of early trophoblast• Due to a developmental anomaly of the placental tissue

with the formation of a mass of oedematous and avascular villi

• The placenta is replaced by grape-like vesicles (the hyatidiform mole)

• Arise from fertilazation by 2 sperm• Benign moles remain in the uterine cavity• 16% of benign moles invade the myometrium• 2.5% leading malignant choriocarcinoma


Hyatidiform Mole

• Locally in the vagina• Through blood borne mets to the lungs


Q – Where can choriocarcinoma spread to?

• Complete mole – diploid (XX) entirely paternal – sperm fertilizes an empty oocyte

• Partial mole – triploid (XXY) variable evidence of foetus.


Q – What is a complete mole and what is a partial mole?

• Bleeding in 1st half of pregnancy• Severe vomitting• Symptoms of pre-eclampsia• Unexplained anaemia • No pain• May pass grape-like villus• May be detected in routine USS


Q - How does it present?

• USS – SNOW STORM APPEARANCE if a complete mole

• Increased HCG in blood/urine• Diagnosis is confirmed histologically


Q – How do we diagnose?

• Once diagnosis established:– Terminate pregnancy (ERPC)– Replace blood loss

• Follow up – repeat hCG at regular intervals for at least 6 months

• Avoid pregnancy and taking COCP until HCG normal


Management

• Hypertension with significant proteinuria after 20wks gestation.

• Hypertension = BP >140/90• Significant proteinuria = 300mg/24hrs

• Complicates up to 10% of pregnancies


Pre-eclampsia

• Nulliparity• Prev. Hx of pre eclampsia• Multiple pregnancy• Chronic hypertension• DM• BMI > 35• Age over 40• CKD• Family history • If high risk – give low dose aspirin prophylaxis


Q – what are the risk factors?

• Headache• Visual disturbances• Vomiting• Oedema of face/hands/feet• Epigastric pain

• Signs:• Clonus• Hyperreflexia• Papilloedema • hypertension


Q – what are the clinical Features?

• Maternal– Prothrombotic – low platelets – can lead to DIC– HELLP (Haemolysis Elevated Liver enzymes Low

Platelets)– Hepatic failure – Renal failure– CNS – eclampsia, cerebral haemorrhage


Q – What are the potential complications?

• Foetal– Oligohydraminos– IUGR– Placental abruption– Prematurity– Foetal death


• Aim to prevent eclampsia and further complications.• CONTROL BP – Labetolol/nifedipine/

methyldopa• SEIZURE PREVENTION – Magnesium Sulphate• STEROIDS – give if <34 wks to promote foetal lung

development• Fluid management• DELIVERY IS THE ONLY CURE!

– Before 34 wks consider C-section– Induce labour when safe!


Management


Any Questions?

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