Obstetrics and

gynaecology
Final Year Revision

Mark Breakdown
200 Marks
40: continuous assessment
80: Viva
80: End of year exam
8 SAQs
40 MCQs

How do you know what will come

up?
Obstetrics
Maternal medicine
Fetal medicine
Labour ward
Antenatal clinic

Gynaecology
Urogynaecology
Gynae-oncology
Fertility
General gynaecology (inc. contraception)

Quick review

OBSTETRICS

What will be covered

Disorders of early
pregnancy

Miscarriage
Stillbirth
Ectopic
APH

Fetal medicine

Antenatal screening
Vertical transmission
At risk fetuses
Monitoring during
pregnancy

Maternal medicine
Maternal conditions of
pregnancy
Gestational diabetes
VTE
PET
Sepsis
Psychiatric

Labour ward

The normal labour

Instrumental delivery
Caesarean section + VBAC
Emergencies

DISORDERS OF EARLY
PREGNANCY

28 year old female, LMP 8 weeks ago, presents

with abdominal pain and PV bleeding

Ectopic pregnancy
Incidence
Worldwide, remains the
leading cause of maternal
death in first trimester
14.8/1000 maternities
(HIPE, 2012)
Accounts for 6% maternal
deaths

Risk factors
Infertility (2x RR)
Tubal pathology (3x RR)
Documented salpingitis
(4x RR)
Pregnancy with previous
sterilisation or IUD in situ
Previous ectopic (10%
recurrence if one previous,

Presentation
5% present in
haemorrhagic shock
Pain, PV bleeding
Diarrhoea, dizziness

Ectopic-Ix
TVUS
Discriminatory zone
>1500
60% ectopics seen
as a
nonhomogenous
mass adjacent to
the ovary
Bagel sign
(hyperechoic ring)
in 20%
13% gestational sac
with fetal pole

Paired serum hCG

0+48 hours
Normal: double
every 2 days
>70% women with
an ectopic will have
<50% rise of a
decline in hCG

Management of ectopic
Expectant
Minimal symptoms
Will comply with follow up
hCG<1000 and falling

Medical
Methotrexate (DHFR
inhibitor) IM. Calculate by
body weight
C/I: blood dyscrasia, TB,
HIV, hepatic or renal
disease
Wait three months before
trying for pregnancy
again

Surgical
hCG>1500
Visible EP sac with cardiac
activity
Mass>35mm
Unstable patient
Laparoscopic or
laparotomy
Salpingectomy or
salpingotomy
No significant difference in
fertility or incidence of
recurrent of ectopic

For all mx
Follow hCG until it reaches
non pregnant levels
Anti D (250) if Rh-

Miscarriage
Pregnancy loss <24 weeks gestation
or <500g
10-20% pregnancies
Divided into first trimester (<12
weeks, 80%) and second trimester
(late, 0.5% risk in low risk women)
50% miscarriages are due to a non
recurrent chromosomal abnormality

Miscarriage-risk factors
Maternal
Age, smoking, obesity, alcohol, cannabis,
cocaine

Infection
Toxoplasmosis, varicella, listeria, malaria, CMV

Medical conditions
Diabetes, SLE, AIDS, Ebola (!)

Anatomical
Uterine abnormalities, conization, cervical
weakness

Miscarriage-presentation
Abdominal pain and pv
bleeding
Differential

Miscarriage
Ectopic
Ruptured CL cyst
GTD
Degenerating fibroid
Ovarian torsion
PID
Endometriosis
Local bleeding (cervical,
vaginal
Heterotopic pregnancy

Initial Mx and Ix
Stabilise
Focused history and
exam
hCG, TVUS, serum
progesterone
Progesterone: <25mmol/lassociated with
pregnancies subsequently
confirmed to be non viable
Beta hCG should double in
48 hours. Discriminatory
zone >1500.

Types of miscarriage
Missed/delayed
Fetal demise, no uterine activity.
Empty sac (mean gestational sac diameter>20mm with not fetal
pole OR no fetal heart with fetal pole>7mm)

Complete
All products of conception passed
Intrauterine tissue diameter <15mm

Inevitable
Open os, POC not expelled

Threatened
PV bleed, closed os
Viable pregnancy

Septic
+infection

Management
Conservative/expectant
Successful in 2-6/52 in >80%
incomplete, 30-70% missed
40-50% women will choose
Repeat U/S 10-14 days post
event to ensure miscarriage is
complete

Medical
Misoprostol 2x600mcg, 6
hours apart (PGE1 analog)
Mifepristone (progesterone
antagonist)
Success: >80% incomplete, 4090% delayed
Medical/expectant mx in
women with 24 phone access,
ED nearby, gestational
sac<50mm

Surgical (ERPC)
Success>95%
Suction curettage
Indications

Patient preference
Heavy PV bleeding
Septic miscarriage
Haemodynamic instability
?GTD

Risks
Infection 0.2%
Bleeding 1%
Damage to local structures
(uterine perforation 1/250)
Retained POC (1% need a
repeat ERPC)

Recurrent miscarriage
>3 consecutive
trimester losses
Primary: no previous
successful pregnancy
Secondary: prior pregnancy
reached viability

**Still a 60% chance of a

subsequent successful
pregnancy
Ix: APL, TFT, HbA1c,
FSH/LH, karyotype,
ultrasound, analysis of
POC

Early
70% idiopathic
4% genetic: parental
karyotype. Rx: prenatal
diagnosis, or IVF and
preimplantation screen
Anatomical abnormalities:
hysteroscopy
Antiphospholipid antibodies

Late
Cervical incompetence
(Shirodkar cerclage)
Infection (*bacterial
vaginosis)

Stillbirth and IUFD

Stilbirth
NPEC definition: >24 weeks or >500g.
Incidence: 5 per 1000 live births
Perinatal death: stillbirths+early neonatal deaths (first 7 days life).
6.2/1000 births

Causes
Fetal structural abnormalities (26% stillbirth)
Placental conditions (24% stillbirth)
Maternal uterine abnormalities
Cervical insufficiency
Thrombophilia: FVL, Protein C/S deficiency, prothrombin mutation,
APL
Infection
PET
GDM
Obstetric cholestasis
APH: vasa praevia, abruption, PP, trauma

Management
Exam
Vital signs, Abdominal exam, speculum
+/- vaginal exam (*only if membranes
unruptured)

Ix:
Labs:
FBC, U+E, LFT, CRP
Coag, fibrinogen (sepsis, abruption, PET),
group+screen, Kleihauer,
Cx-urine, blood, swabs

Management
Delivery
NB NB Infection
Fetal demise + ROM, cervical dilatation-induce
Medical: induce with mifepristone 200mg,
misoprostol (SE: fever, NVD, contractions). Delivery
occurs within 24 hours of IOL in 90%
Expectant mx an option if

Physically well
Closed cervix, intact membranes, no PET
85% deliver spontaneously within 3/52 of diagnosis
10% risk coagulopathy 4/52 after fetal demise

Dont forget Anti-D

Investigations
Maternal
FBC, U+E, CRP, bile
acids, LFTs, uric acid
Coag
Thrombophilia screen
TFTs
HbA1c, random blood
glucose
Serology
Toxicology
Karyotype (+paternal)
Swabs: cx, blood cx

Foetal
Cord/cardiac blood
Microbiology
Karyotype (6% will
have an
abnormality)
Placenta+membran
es
Autopsy
*50% no cause
found

APH
Causes
Placenta praevia
Placental abruption
Velamentous
insertion of cord
Vasa praevia
Local genital tract
trauma

60% have no
identified risk factor

Risk factors
Abruption
Hypertension
Substance misuse (cocaine,
smoking)
Trauma
Previous abruption
Parity
Polyhydramnios
Multiple gestation
IOL
ECV

Praevia

Prior PP
Multiple gestation
Multiparity
Prior uterine instrumentation or
surgery
Uterine anomalies
Advance maternal age

Placenta praevia
Grades
1: in lower segment but
doesnt reach os (>2cm)
2: abuts the os
3: covers the os
4: lies centrally over the os

15-20% women have a low

lying placenta at 20/40.
Only Grade 3-4 should be
offered another scan at
32/40.
5% will still be low lying at
32/40 and only 1/3 of these
will be low lying at term

Complications
Maternal

APH
PPH
Intrapartum hemorrhage
Massive transfusion
Shock and death
DIC
Renal failure
Sheehans syndrome (necrosis of
anterior pituitary)
Invasive implantation

Foetal

Distress
HIE
Anaemia
Death
Iatrogenic premature delivery

Placental abruption
Rate: 1/120.
Presentation

Abdominal pain
+/-PV bleeding
Woody uterus
Abdominal tenderness
Hypovolemic shock
Remember, a pregnant woman
can lose 30-40% blood volume
before becoming symptomatic

Decreased fetal movements

Ix
Clinical diagnosis
Ultrasound will miss of
abruptions

Mx
Call for help
ABC and stabilise
Labs: Group and X match, FBC,
coag, Kleihauer
Assess foetus
TAUS
CTG >28/40

Plan for delivery

Gestational age and growth
Maternal condition

Steroids 24-33+6/40
MgSO4 for neuroprotection<32
weeks if delivery required
Anti D if Rh-ve

Invasive implantation
Placenta accreta
Abnormally adherent placenta

Increta
Placenta invades myometrium
but not serosa

Percreta
Placenta passes through
serosa and adjacent structures

Aim to diagnose early and

plan for elective delivery
Diagnosis
Doppler ultrasound: spiral
arterioles
MRI

Risk factors
Previous uterine
instrumentation

Complications

PPH
Hysterectomy
Uterine inversion
Failure to remove
placenta completely
Sepsis
Choriocarcinoma

FETAL MEDICINE

Ultrasound
Confirm gestation
Dating scan
CRL up to 14 weeks, then
Hadlock measurements

Location of pregnancy
Intrauterine, ectopic

Placenta
Praevia

Exclude multiple gestation

Screening
Chromosomal abnormalities

Diagnosis
Structural abnormalities

Aid in
CVS
Amniocentesis
Fetal procedures
e.g transfusion
Laser ablation in
TTTS

Antenatal screening
20 week anatomy scan
Cardiac anomalies
1% pregnancies
Risk: Congenital cardiac disease, previous baby affected (recurrence
3%), diabetes, other structural abnormalities
Increased nuchal translucency

Neural tube defects

1/200 pregnancies
High dose folic acid for high risk patients
Previous baby with NTD, personal hx NTD, diabetes, AEDs

Abdominal wall defects

Gastroschisis
Omphalocele: 50% affected have a concurrent chromosomal
abnormality
Duodenal atresia: T21, double bubble, polyhydramnios
TEF: small stomach, polyhydramnios

Renal defects
Potters sequence: renal agenesis->oligohydramnios->pulmonary

Other screening
All optional
Non invasive (examples for
T21)
Triple test
Increased beta hCG, increased
inhibin, decreased PAPP-A

Nuchal translucency
Increased NT (>6mm), absent
nasal bone, absent flow in DV)

Quad screen
Increased hCG, increased inhibin,
decreased AFP, decreased
unconjugated E2

Integrated screen: NT+quad

screen
Harmony
Cell free fetal DNA (DNA comes
from trophoblast cells)

Invasive
Chorionic villus
sampling
11/40
Risk fetal limb
reduction
2-3% risk miscarriage

Amniocentesis
15-16/40
1% risk miscarriage
Use fibroblasts for
karyotype

Vertical transmission
HIV
Interventions have reduced
the rate of HIV vertical
transmission to <1%
Transmission highest in
labour
Maternal HAART from T2
Aim for undetectable viral
load
Vaginal delivery possible

Breastfeeding
contraindicated
START for infant
(zidovudine)

Hepatitis B
dsDNA
95% risk vertical
transmission (vs 4%
for Hep C)
High risk: maternal
HBeAg +ve,
indicates high
disease activity
Rx: neonatal hep B
vaccination and Ig

Vertical transmission
Toxoplasmosis
15% population
already immune
Foetal/neonatal effects
Chorioretinitis
Intracranial calcification
Hydrocephalus

Rx: spiramycin
Risk of transmission
increases with
gestation
T1: 14%
T2>50%

Varicella
90% population already
immune
0.12/1000 live births
affected
>28/40: 0% risk
transmission
Foetal effects
Segmental limb scarring

Management
Exposure and mother non
immune: VzIG +/- aciclovir
Rash 7 days before or after
delivery: neonatal VzIg

Vertical transmission
Rubella
ssRNA
98% immune
Foetal effects
PDA, hearing loss
(Organ of Corti),
microcephaly,
cataracts

Risk of transmission
decreases with
gestation
T1: 90%
T2: 0%

Parvovirus B19
0.25% women infected in
pregnancy
Regular U/S for 6/52 if IgM
+ve
Anaemia
Monitor fetal movements

Syphilis
RPR, FPA
Numerous fetal effects
Sabre shins, mulberry
molars, cardiac anomalies,
snuffles

Transmission risk
increases with gestation
Rx: Maternal penicillin

Vertical transmission
CMV
30% already immune
40% vertical
transmission of which
10% will have
cytomegalic inclusion
disease at birth
Foetal effects
Blueberry muffin baby,
hepatosplenomegaly,
jaundice, sensorineural
hearing loss

HSV 1+2
90% population already
exposed
First outbreak in
pregnancy: <6 weeks prior
to delivery-C/S
Rx: aciclovir
Chlamydia and gonorrhea
Ophthalmia neonatorum
Gonorrhea: day 2-3,
purulent exudate
Chlamydia: day 4-5, clear
exudate. Also risk of
pneumonitis

FGR
Only 1/3 FGR
pregnancies are
recognised
prenatally
8x increase in
stillbirth
Risk of adverse
outcome
<3rd centile
Abnormal UA
measurements

Causes
Normal small
Constitutional
Symmetrical

Abnormal small
Symmetrical
Chromosomal
Vertical infection

Asymmetrical
Placental
insufficiency
Brain sparing

FGR
Mx
High risk: scan 2-4 weekly
from 26 weeks
Customised centiles

Growth velocity scan

If growing normally and normal
UA and AFV, then 2 weekly
scans.

Anatomy scan
20-22 weeks
Association of IUGR and
genetic syndromes, aneuploidy
and intrauterine infection
Concomitant structural
abnormalities, polyhydramnios
or soft markers

Surveillance growth
scans
Look at fetal soft markers,
placental pathology, AFV
and UA dopplers

Delivery
SGA with no other
abnormalities
IOL or elective delivery at
37-38 weeks

Doppler abnormalities
Increased pulatility index
Absent end diastolic flow
Reversed end diastolic flow

FGR Delivery
If UA Doppler increased pulsatility
index (>95th centile):
Weekly monitoring.
Delivery no later than 37 weeks
IOL is possible with careful CTG
monitoring.
PORTO study mean time-to-delivery
interval: 26 days

If UA Doppler absent end diastolic

flow:
Admit.
Daily CTG.
Twice weekly scans for UA Doppler
assessment and AFV index.
Deliver no later than 34 weeks.
Steroids, one dose, timed manner,
definitely up to 34 weeks, and
consider up to 38 weeks if delivery
via elective c section.
Magnesium sulphate <32 weeks for
fetal neuroprotection.
PORTO study mean time-to-delivery
interval: 12 days

If UA Doppler reversed end

diastolic flow:
Admit.
Daily CTG.
Thrice weekly scans for UA Doppler
assessment and AFV index.
Deliver no later than 30 weeks.
Steroids.
Magnesium sulphate for fetal
neuroprotection.
Most will be delivered by Caesarean
section, they do not tolerate labour
well. If considering IOL, then
continuous CTG monitoring with low
threshold for caesarean section.
PORTO study mean time-to-delivery
interval: 4 days

FGR Post natal care

Cord arterial and venous pH
Histopathological examination of
placenta
Non infectious chronic villitis of
unknown aetiology: linked to maternal
obesity, tends to recur in a more severe
degree in subsequent pregnancies.
Fetal thrombotic vasculopathy has been
described in association with parental
hemophilias so thrombophilia testing in
both parents may be indicated
Massive fibrin deposition and maternal
floor infarction is rare and due to
maternal malperfusion,
hypercoagulability and trophoblast
injury, recurs in up to 50% cases
Placental infarctions are associated with
placental developmental abnormalities,
treatment with LMWH has the potential
to improve placentation and outcome

Bring mum back for follow up visit

to discuss results,
Consider thrombophilia screen,
Modify risk factors n.b smoking
Discuss prevention and management
in future pregnancies
Recurrence rate 25%.
Next pregnancy will be high risk and in an
obstetrician led clinic.
Encourage to book early.
Measure fundal height at each visit and
consider customised centile chart.
Have 2-4 weekly sonographic surveillance
from 26 weeks with AFV measurement and
UA dopplers.
Consider low dose aspirin, starting at <16
weeks, especially if placenta mediated
FGR, maternal hypertensive disease or
antiphospholipid syndrome.
Consider LMWH for women with placental
dysfunction.

Multiple pregnancy
Maternal

Increased risk all complications

Hyperemesis
GDM
PET
Preterm labour
PPROM
VTE
Placenta previa
Abruption
Haemorrhage (APH,IPH,PPH)
Miscarriage
Surgical delivery
Cord prolapse

Fetal
Prematurity (50% tiwns, 90% triplets)
Malpresentation
Growth discordance: 18% increases
perinatal morbidity
Difficult birth
Interlocking

Specific complications
Determine chorionicity at 12 weeks
Lambda sign-DCDA
T sign Monoamniotic

MCMA
Highest risk overall
Less TTTS than MCDA
20% deliver<32 weeks

MCDA (10-15% twin pregnancy)

TTTS
Screen: US at 16/40 then every 2-3 w: BPP,
AFI

TRAP: twin reversed arterial perfusion

sequence
Single fetal demise
Risk of late in utero death

Delivery
ESPRIT study (Ireland)
Uncomplicatied monochoirionic may
continue to 37/40, dichorionic to 38/40
Reduces risk of neonatal morbidity fom
88% to 9%

Twin twin transfusion

Quintero et al staging
1: Maximum vertical
pocket (<2cm donor,
>8cm recipient)
2: Fetal bladder anomaly
3: Doppler anomalies
Donor: arterial
abnormalities, absent EDV
in UA
Recipient: Reverse flow in
DV

4: Hydrops fetalis
5: Fetal demise of one or
both twins

Rx
Laser
photocoagulation of
placental
anasomoses <26
weeks

Oligohydramnios
Single deepest
pocket<2cm
Causes
Maternal
Medications e.g ACE

Placental
Uteroplacental insufficiency
(PET, smoking ,substance
misuse)

Fetal
FGR with brain sparing
Renal tract anomalies e.g
agenesis, posterior urethral
valves

Pregnancy related
PPROM
Post dates

Complications

Pulmonary hypoplasia
Potters sequence
Cord compression
Increased adverse
outcomes

Mx
Admit
R/O ROM
Fetal U/S :*Umbilical
doppler
Maternal hydration
Treat the cause

Polyhydramnios
Liquor pool>8cm or
AFI>95th centile
1% all pregnancies
2-5x increased perinatal
mortality
Causes
Maternal
Diabetes
Renal failure

Fetal
TEF, atresia
Myotonic dystrophy
Chromosomal anomaly

Twins
TTTS

Idiopathic

Complications
PTL
Abnormal lie,
malpresentation
Cord prolapse
Abruption
PPH

Mx
Fetal assessment-U/S
Maternal OGTT
Options to decrease liquor
(if <34 weeks)
NSAIDS decrease fetal urine
output
Amnioreduction

Delivery
Vaginal usually possible

MATERNAL MEDICINE

Rhesus disease
Blood group and
antibodies at booking
and 28/40
15% Caucasian women
Rhesus ve (dd)
Chromosome 1
Anti D prevents
isoimmunisation (1.5%0.2%)
Given routinely at 28/40
(1500iu)
Given at sensitising events
within 72 hours

Sensitising events

Miscarriage>12 weeks
APH
Ectopic pregnancy
Molar pregnancy
ERPC
TOP
Invasive prenatal
procedures
CVS, amniocentesis, FBS,
external version

Closed abodminal injury

IUFD/stillbirth
Post partum if infants
blood group Rh+

Rhesus disease
If mother is already
sensitised
Rhesus disease will
worsen with each
subsequent pregnancy
Fetal haemolysis and
anaemia
Measure antibody
levels every 2-4 weeks
4-15 IU/ml: moderate
risk hemolytic disease
>15 IU/ml: high risk of
hydrops

Mx
Regular fetal
ultrasound
Peak velocity in
systole of MCA
Hydrops

In utero transfusion
Restore Hb levels
Suppress
erythropoeisis

Hyperemesis gravidarum
Affects 1% pregnancies
50% those with abnormal LFTs
66% if abnormal TFTs

Complications
Maternal

Dehydration
Metabolic alkalosis
Vitamin deficiency (B1,B6)
Risk Wernickes (nystagmus, ataxia,
confusion
Mallory Weiss tear
VTE

Risk factors
Previous hyperemesis, family
history
Thyrotoxicosis
Hx motion sickness
Lower BMI
Molar pregnancy
Multiple pregnancy
Extremes of age

Dx
Fairweather criteria

>3 episodes emesis/day

Weight loss
Ketonemia
Electrolyte imbalance and volume
depletion

Fetal
LBW, poor Apgars, PTB

Mx

Reassurance
Hydration: Hartmanns
Cyclizine/ondansetron
Supplementation (Pabrinex)
Thromboprophylaxis
Oral steroids
Doxylamine + pyridoxine (not
licenced in Ireland)

Anaemia in pregnancy
FBC: Booking and 28/40
Iron deficiency anaemia
Many women enter pregnancy with low stores
Requirement double (to 6g/day) during prengancy
Increased risk maternal infection, PP depression and heart
failure. Fetal risks-prematurity, LBW, iron def anaemia

Physiologic anaemia
Dilutional
Increased plasma volume mass relative to red cell mass
Reason for varying definitions of anaemia/trimester
T1: 11.0 g/dl
T2: 10.5 g/dl
T3: 10.0 g/dl

UTI in pregnancy
Increased susceptibility
Dilatation of ureters and renal pelvis.
Raised plasma volume and GFR
Always treat asymptomatic bacteriuria
in pregnancy
Rx: nitrofurantoin (though risk fetal
anaemia), co-amoxiclav
Decrease risk of preterm labour,
chorioamnionitis, adverse fetal
outcomes

VTE
Most common cause
direct maternal death
in most recent
triennium (MBBRACE)
High risk: 60/100 000
pregnancies
Risk assessment

Pre conceptual
At booking visit
At hospitalisation
At delivery
On discharge

Rx: LMWH as required

Pre existing risk factors

Personal history (RR
3.5)
Family history
BMI>30
Maternal age >35,
parity>3
Smoking
Medical comorbidities

Varicose veins
Haematological ocndition
Nephrotic symdorme
Paraplegia
IVDU

VTE
Transient risk factors
Hospital admission
Surgery in
pregnancy/puerperium
Immobility (>4 days)
Blood loss (>1L)
Systemic infection
PP wound infection
Hyperemesis
Dehydration
PET
Multiple pregnancy
OHSS
Assisted reproduction

Mx
>2 risk factors: LMWH
Personal history: antenatal
and 6 weeks postnatal
prophylaxis
Emergency C/S:
thromboprophylaxis until
discharge (7 days)
Documented thrombophilia:
6/52 post partum
thromboprophylaxis
Recurrent miscarriage and
APL: LMWH and aspirin
Stop LMWH when labour
commences
No regional anaesthesia until >12
hours after last dose

DVT/PE Management
Swollen leg
Compression
ultrasound
Start LMWH 1mg/kg
BD until diagnosis
excluded

SOB, haemoptysis,
signs of PE
Stabilise
Ix: FBC, U+E, coag,
LFT, CRP

CXR
To exclude other pathologies

If CXR negative and high

suspicion
CTPA
Increases risk of maternal
breast cancer by 5% to 13.6%
V/Q scan
Increased risk childhood
cancer (1/280,000 vs
1/1million)

If CXR negative and lower

suspicion:
Bilateral doppler US

Diabetes in pregnancy
2-3% women lose babies
due to diabetes
Pregnancy is a
diabetogenic state
Hormones: hPL,
progesterone, cortisol, GH
Lifestyle factors: less
exercise, increased calories,
increased fat deposition

75 OGTT at 24-28 weeks

Dx:
Fasting 5.1 mmol/l
1 hour 10 mmol/l
2 hours 8.5 mmol/l

Selective screening

Family history
BMI>30
Age>40
Ethnicity
PCOS
Long term steroid use
Previous big baby
Previous unexplained
perinatal death
Current glycosuria
Polyhydramnios/macroso
mia in pregnancy

Pre existing diabetes

Maternal implications
Poor blood glucose control
Increased insulin requirement:
increase during second
trimester, decrease in latter part
of third trimester
Maternal hypoglycaemia (risk of
sudden death, nighttime hypos
and lack of awareness)
Exacerbation of diabetic
retinopathy (3 retinopathy
checks required during
pregnancy)
Deterioration of renal function
(hypertension-early onset
hypertension or PET)
Pre eclampsia

Fetal implications
Increased risk miscarriage
Increased risk stillbirth
Increased risk congenital
anomalies
Cardiac anomalies,
sirenomelia and sacral
agenesis, NTDs (high dose
folate)

Macrosomia or IUGR
Polyhydramnios
Neonatal

Shoulder dystocia+palsy
Respiratory distress syndrome
Hypoglycemia
Hypocalcaemia
Polycythemia

PET
2-3% all
pregnancies
5-7% primips
Dx
BP>140/90+protein
uria (0.3g in 24
hours) after 20/40.
Resolves within
6/52 post partum

Risk factors
Nulliparity
Previous disease (15% risk
recurrence, 50% recurrence if
severe PET<28/40)
Family history
Age >40
>10 years since last
pregnancy, new partner
Obesity
Chronic hypertension
15-25% women with gestational
hypertension will develop PET

Renal disease
Diabetes
Autoimmune diseases
Increased placental mass:
twins, molar pregnancy

PET
Complications

Stroke
Eclampsia (0.05%)
Cortical blindness
Posterior reversible
encephalopathy
syndrome
ARDS, pulmonary
oedema
HELLP
Liver capsule rupture,
liver failure
DIC
Renal failure
VTE

Accounts for
5% stillbirths
10% preterm deliveries

HELLP
Haemolysis
Dark urine
Elevated LDH

Elevated liver enzymes: ALT

Low platelets
If platelets <20x10^9, consider
transfusion before delivery
Dexamethasone may improve lab
parameters of women with platelets <50

DVT/PE
Prior to delivery: TEDS, LMWH
Post partum: at least 7 days LMWH

Pulmonary oedema

Fluid overload
Fluid input limited to 80ml/hour
Natural diuresis post partum
Monitor urine output
Consider frusemide

Non severe PET

Mx

Treatment

GP or hospital day unit

Confirm
Sustained elevated BP
Proteinuria
24 urine collection
Protein creatinine
ration>30ng/mmol

Labs
FBC, U+E, uric acid, LFT, coag
(only if platelets are abnormal)

Fetal assessment
At dx and q4 weeks thereafter
US: weight, growth, AFI,
Doppler UA

Aim for BP 130-155/80-105

Labetalol
Alpha and beta adrenergic antagonist
100mg BD/TDS. Max dose 2.4g/day
C/I: asthmatics

Methyldopa
Centrally acting antihypertensive
250mg TDS. Max dose 1g TDS
Side effects: sedation, depression

Nifedipine SR
30mg/day

Delivery
Best way on the best day
HYPITAT trial: recommended
IOL>37 weeks
Take into account

Womans symptoms
Fetal wellbeing
Favourability of cervix
Severity of PET

Severe PET
Eclampsia
Severe hypertension
(BP>160
Symptomatic
Headache+visual
disturbances
Epigastric pain
Clonus
Liver tenderness
Platelets<100x10^9
ALT>50 IU
Creatinine>100 mmol/l

Mx
Admit and monitor

HDU, inform consultant

ABC
IV access
Labs
FBC, U+E, uric acid, LFT,
clotting, group+hold

Regular obs
Fetal well being
US, CTG

Fluid management
Thromboprophylaxis

Severe PET
Mx
Control BP
Labetalol 200mg PO stat
30 minutes to action
Bolus labetalol 50mg IV
Labetalol infusion

Hydralazine 2.5mg IV bolus

Nifedipine 20mg

Seizure prophylaxis
MgSO4 4g IV followed by
1g/hour
Magpie trial: 80% seizures
prevented by prophylaxis
Reflexes q4hours, RR
Antidote: 10ml 10% calcium
gluconate

Plan for delivery

<34 weeks: steroids, C section
>34 weeks: IOL
Continue antihypertensives
throughout labour
Epidural analgesia
Pushing is allowed once BP is
controlled
No ergometrine in the third stage

Post natal

Fluid restrict, DVT prophylaxis

Monitor in hospital until at least d3
4 hourly BP, daily labs
Discharge once BP stable and
bloods normalising
Measure BP daily for 2 weeks
Follow up hospital appointment 8
weeks after delivery
Secondary prevention: 75mg
aspirin

Eclampsia: emergency
Call for help: ocnsulatn obstetrician,
anaesthesist, neonatologist
ABC and IV access
Loading dose MgSO4 followed by
maintenance
Diazepam 5-10mg IV
Labetalol bolus
Delivery once stabilized

Liver disease in pregnancy

Elevated LFTs
Gallstones: increased lithogenicity of bile, bile
stasis
Viral screen: hepatitis, CMV, EBV
Autoimmune screen: anti smooth muscle, anti
mitochondrial
PET +/- HELLP
Obstetric cholestasis
Dx exclusion. Increased risk stillbirth
(controversial), elevated bile acids, Rx
ursodeoxycholic acid. No rash.

LABOUR WARD

Preterm labour
Regular contractions
accompanied by cervical
change <37 weeks gestation
Dx: clinical
Spontaneous preterm labour
Intact membranes (40-45%
preterm births)
Preterm prelabour rupture of
membranes (25-30% preterm
births)

Differentiate from delivery for

maternal or fetal indications
Induction or prelabour C section
30-35% all preterm births
Commonly pre eclampsia,
eclampsia, haemorrhage, fetal
growth restriction (IUGR and
abnormal dopplers)

Regarded as a syndrome
Infection or inflammation
Vascular disease: uteroplacental
ischaemia or haemorrhage
Uterine overdistension
Stress and other immunologically
mediated processes
Precise mechanism usually not
established

Management

Alert multidisciplinary team

Antenatal steroids
Erythromycin
MgSO4
Tocolytics (calcium channel
blocker nifedipine or atosiban
oxytocin antagonist) used to give
time for steroids to work and to
transfer to tertiary care

Preterm labour
Pregnancy characteristics

Risk factors
Maternal risk factors
Black, African, AfroCaribbean
Interpregnancy interval of
<6 months
Nutritional status: low
prepregnancy BMI.
Family history
Previous preterm birth (2.5x
RR)

Environmental
Smoking, cocaine, heroin
Psychological or social stress
Clinical depression

Multiple births
Antepartum haemorrhage
Intrauterine infection
(mycoplasma, u urealyticum,
bacterial vaginosis)
Non genital tract infections:
pyelonephritis, pneumonia,
appendicitis
Periodontal disease
Polyhydramnios or
oligohydramnios
Maternal abdominal surgery
Maternal medical disorders:
thyroid,asthma,diacetes,
hypertension
Cervical cone biopsy
Uterine anomalies

PPROM
Preterm prelabour rupture
of membranes
Risk factors

Maternal age (advanced)

Smoking
Diabetes
Maternal infection
PET
Cervical shortening
Twin pregnancy
Polyhydramnios
Uterine abnormalities
(fibroids, bicornuate uterus)

Diagnosis
Sterile speculum and
visualisation of fluid pooling
in the posterior fornix is the
method of diagnosis used in
CUMH
This is backed up by a TAUS
showing decreased AFI
Other methods of diagnosis:
Amnisure, an immune assay
with good sensitivity, expensive
Nitrazine test (contamination
by blood, semen or vaginal
discharge can give false
results)
Ferning of fluid on slide

PPROM
Mx

Differential
Discharge
Incontinence
Bleed

Ix
Urinalysis and MSU for
microscopy and culture
Bloods: FBC, CRP, group
and save (if precipitate
delivery likely), cultures
High vaginal swab
(bacterial vaginosis), low
vaginal swab and rectal
swab (group B strep)
Trans abdominal
ultrasound

Admit
Monitoring:
I will monitor her vital signs
every 4 hours or according to
MEWS score
Bloods: twice weekly
Scans: biophysical profile,
particularly looking at AFI. Serial
growth scans
CTG: monitoring after 28 weeks

Treatment
Erythromycin 250 mg QDS for
10 days.
Kenyon et al, 2010 performed a
review and meta analysis of the
literature which showed that
this decreased perinatal
infection and prolonged
pregnancy

Magnesium sulphate<32 weeks

PPROM
Delivery
Contentious issue.
Expectant management
until 34 weeks if no
complications
Deliver after 37 weeks
Between 34-37 weeks,
Cochrane review in
2010 concluded there
was insufficient
evidence to make a
recommendation. Take it
on a case by case basis.

Complications
Maternal:
Chorioamnionitis,
sepsis, premature
labour

Fetal
Pulmonary
hypoplasia
secondary to
anhydramnios,
premature delivery

Consent for a caesarean

section
Risk of anaesthetic
Serious risks
Death (1/12,000)
Emergency
hysterectomy
(8/1000)
Bladder (1/1000)
Ureteric damage
Further surgery
ICU admission

Frequent risks

Pain (9/100)
Infection (6/100)
Haemorrhage (5/1000)
Readmission
Fetal laceration

In future pregnancies
Repeat C/S (1/4)
Placenta praevia (48/1000)
Uterine rupture (27/1000)
Stillbirth (1-4/1000)

VBAC
72-76% chance of
success
Previous vaginal delivery
the biggest predictor
Cervix favourability
Previous indication for C
section

Benefits

Vaginal birth
Shorter stay
Quicker recovery
Decreased risk in future
pregnancies

Risks
Uterine rupture (1/200)
Classical C/S scar: CI
IOL: 4x increased risk
Number of previous
sections 3x increased
risk
<12 months since last
C/S

Need for emergency

C/S
Infection, transfusion

Counsel this woman about a

VBAC
Review of womans complete obstetric history
C/I to VBAC: placenta praevia, classical C/S

Assessment of risks of VBAC vs. risks of repeat

section
Individual assessment of likelihood of successful
VBAC (NICH online tool)
Enquiry into womans understanding of risk and her
desire for future pregnancies
Specific plan for delivery including contingencies e.g
management if a woman presents in spontaneous
labour prior to scheduled elective repeat C/S

Breech presentation
3-4% pregnancies at
term
Types
Frank: flexed hips,
extended knees,
70%
Complete: flexed
hips and knees. 10%
Footling: foot or knee
presenting, 30%

Risk factors
Idiopathic
Maternal
Uterine anomalies
Grand multip
Uterine surgery

Fetal

Multiple gestation
Preterm
Fetal anomaly or aneuploidy
Congenital malformation (2x RR)
Abnormality in tone

Maternofetal
Placenta previa
Polyhydramnios

Breech presentation
Management

External cephalic version

60-75% successful
Done at 37/40
Before:

CTG
Left lateral tilt
Empty bladder
Nifedipine (tocolytic)

During: US guidance
After:
CTG
Anti D if Rh-

Complications

Cord compression
Transplacental haemorrhage
Abruption
Prelabour ROM

Contraindications to ECV
Previous C section or uterine
scar
History APH
PET or hypertension
Placenta previa
Oligo/polyhydramnios
Multiple gestation
Fetal anomaly

Breech presentation
Hannah Term
Breech Trial
Vaginal delivery
carries 3x RR
neonatal morbidity
and mortality
Recommend C/S for
all
Controversial

Vaginal delivery
Frank or complete
breech
>36 weeks
EFW 2500-3500
Flexed head
Continuous EFM
2 experienced
obstetricians
Ability to perform
emergency C/S if
required

Perineal tears
Risk 2-3%
RCOG classification
(Sultan et al)
1: perineal skin only
2: incolving perineal
muscles but not anal
muscles
3a: <50% external anal
sphincter
3b: >50% external anal
sphincter
3c: External and internal
anal sphincter
4: through anal mucosa

Risk factors

Long labour
Large baby
Forceps delivery
Midline eipisiotomy
Shoulder dystocia
Epidural
IOL
Nulliparity

MX

Repair: surgical sutures

Antibiotics:augmentin, flagyl
Analgesia
Stool softeners
Physio and pelvic floor
exercises
F/U in Perineal OPD in 4-6/12

Shoulder dystocia
Bony impaction
Diagnosed when additional
maneouvres are required to
deliver the fetal shoulder after
gentle downward traction has
failed
50% occurs in normal birth
weight infants
Risk factors
Maternal obesity
Maternal weight gain in
pregnancy (>20kg, 10x RR)
Diabetes (3x RR)
Macrosomia
Short stature, small abnormal
pelvis
Previous shoulder dystocia
IOL

Intrapartum
Failure of head to
descent
Prolonged first/second
stage
Oxytocin augmentation
Instrumental birth
Head retraction between
contractions
Difficulty delivering face
and chin
Failure of restitution
Turtle sign
TIME: pH drops by 0.04
every minute

Shoulder dystocia
HELPER-R
Call for help: 20799 and
state emergency
Evaluate for episiotomy
Legs: McRoberts
Flexion, abduction, internal
rotation
Tilts maternal pelvis-horizontal
symphysis, flattens sacral
promontory
Relieves majority of cases

Suprapubic pressure
Adduct anterior shoulder,
decrease bisacromial diameter

Entry maneouvres
Rubins 2: clinicians hand enters
posteriory. Direct pressure to
posterior aspect of anterior
shoulder
Woodscrew: enter hand
anteriorly and apply direct
pressure to anterior of posterior
shoulder and attempt to rotate

Remove posterior arm

Roll on all fours
TIMING
No more than 30s for each
maneouvre

DOCUMENTATION

Shoulder dystocia
Post partum care
Maternal
Prevent PPH
Observe for
perineal pain

Neonate
Resus
Paired cord
pH/lactate
Neonatal review

Complications
Maternal

Psychological trauma
PPH 11%
Uterine trauma/rupture
Perineal lacerations, tears
Transient maternal femoral
neuropathy
Symphyseal separation

Fetal
Brachial plexus injury 216%
Erbs palsy C5/6, waiters
tip
HIE
Death

Uterine rupture
0.02%
Risk factors
High parity
Multiple pregnancy
Previous uterine
trauma/surgery
VBAC
IOL
Mid/high cavity
forceps
Obstructed labour
Internal manipulation
Trauma e.g RTA

Fetal mortality 10x higher

than maternal
Presentation
Abdominal pain, shoulder tip
Cessation of contractions
Haemorrhage (concealed or
revealed)
Fetus
Palpable per abdomen
Loss of station
Fetal bradycardia

Mx

Call for help

ABC
Immediate transfer to theatre
Caesarean
+repair/hysterectomy

PPH
Risk factors
Antepartum
APH: abruption,
praevia
Multiple pregnancy
Grand multip
Age>40 and a primip
PET
Gestational
hypertension
Previous PPH
Obesity
Anaemia

Intrapartum
Prolonged labour
Prolonged pyrexia
in labour
Macrosomic baby
Episiotomy
Instrumental
delivery
C section
Retained placenta

PPH
>500ml blood loss
Primary
4 Ts
Tone
Uterine atony, 70%

Tissue, 9%
Retained products

Trauma, 10%
Cervical laceration
,episiotomy, uterine
rupture

Thrombin, <1%
DIC, vWF, PET/HELLPP,
infection, AFE

Secondary
Septic retained POC

Mx
Call for help
Resuscitate
Assess maintain and
monitor airway
IV access and fluid
resuscitation (IVF followed
by O-)
Take blood: group and
Xmatch, FBC, U+E, LFT,
coag, fibrinogen
Insert foley: in and out
catheterisation
Record vitals every 15
minutes

PPH
Mx continued
Stop bleed and look for
cause
Tone
Assess uterus
Fundal massage
Bimanual massage

Tissue
Inspect placenta and
membranes
Evacuate tissue: Brant
maneouvre

Trauma
Lacerations, episiotomy

Thrombin
Is blood lost clotting?
Consider AFI
Review history: thrombophilia

Medical management
Oxytocin IM 5-10 units
Oxytocin infusion 40 units
in 40ml
Ergometrine 250 mcg IM
Carboprost 250mcg IM
q15 minutes
Misoprostol 1000 mcg PR

If bleeding doesnt stop

Theatre

B lynch suture
Intrauterine Rusch balloon
UAE
Hysterectomy