OBG - hannah cooke obgyn notes PDF

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Obstetrics, Gynaecology and NeonatologyObstetricsObstetric HistoryEstablish patient demographics and gain consent to take a historyPresenting complaint, and history of presenting complaint Onset, duration, course Additional symptoms o PV bleeding o PV discharge o Abdominal or pelvic pain o Foetal mo...

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Obstetrics, Gynaecology and Neonatology Obstetrics Obstetric History Establish patient demographics and gain consent to take a history Presenting complaint, and history of presenting complaint -

Onset, duration, course Additional symptoms o PV bleeding o PV discharge o Abdominal or pelvic pain o Foetal movements o Contractions, labour pains, or tightening feelings ▪ Braxton Hicks contractions may be confused with labour. These are mild, irregular contractions that may occur from 30 weeks’ gestation. These are less painful than labour and do not increase in amplitude, frequency, or duration o Pre-eclampsia symptoms (headache, visual disturbance, oedema, epigastric pain) o Urinary symptoms

Menstrual history, as this enables calculation of present gestation and EDD (ovulation occurs 14 days before the next period, and delivery occurs ~38 weeks after ovulation) -

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LMP, are they sure of this and was this normal Duration (usually 3 – 7 days) and cycle (usually 21 – 35 days), and the regularity of this o This is recorded as X/Y ▪ X = days of bleeding, Y = length of cycle Was the patient taking oral contraceptives

History of the current pregnancy -

How was the pregnancy confirmed? Did the patient take folic acid during the first trimester? Have they had any other scans or tests whilst being pregnant, were these normal? Planned method of delivery Chronological history of any events or medical illnesses during the pregnancy

Past obstetric history -

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Gravidity and parity o Gravidity is the total number of times a woman has been pregnant o Parity is recorded as X + Y ▪ X = any live or stillbirth after 24 weeks, Y = miscarriage before 24 weeks For each pregnancy establish

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o Outcome: live birth, stillbirth, miscarriage, TOP, ectopic/molar For each child establish o Age o Details of pregnancy, labour and delivery o Birth weights o Gestation o Complications (antenatal, labour, or postnatal)

Gynaecological history -

Last cervical smear, and the result of this Previous gynaecological problems or surgery, including STDs Current contraception

The rest of the history is as normal When presenting an obstetric case, it is important to first give a brief summary of the following -

Patient’s name and age Gravidity and parity Maturity of the current pregnancy in weeks Presenting complaints

Obstetric Examination WIPE, and gain consent for the examination -

Today I need to examine your tummy as part of the assessment of your pregnancy, it will involve me having a look and a press of your tummy and performing some measurements of the baby

General inspection, and inspection of surroundings Close inspection -

Hands: pulse rate, capillary refill, palmar erythema, peripheral oedema Offer to take blood pressure Face: conjunctival pallor, jaundiced sclera, oedema

Abdominal examination follows. This should begin with inspection -

General contour and impression of size, note any foetal movements Previous operation scars Striae gravidarum and linea nigra

Palpation, first asking about abdominal pain -

Palpate all 9 sections of the abdomen for tenderness or guarding Lightly palpate the uterus, starting at the xiphisternum using the ulnar border of the hand to identify the fundus, and then feeling for the lateral edges o Fundal height indicates gestation ▪ 12 weeks = pubic symphysis

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▪ 20 weeks = umbilicus ▪ 36 weeks = xiphisternum Place both hands on the uterus to ballot the foetus and determine the following o Foetal lie o Presenting part o Station of the presenting part (engagement) o Position o Amniotic fluid, if excess is suspected assess for a fluid thrill Measure symphyseal-fundal height (only accurate after 20 weeks) use a tape measure facedown to avoid bias, record in cm

Auscultate foetal heart with Pinard stethoscope or Doppler USS To complete the examination perform a urine dip, measure blood pressure, and maternal weight/height. Obstetric Definitions and Palpation Foetal lie is the relation of the longitudinal axis of the foetus to the longitudinal axis of the uterus. One side of the foetus should feel smoother, this is the back, whereas the limbs will feel irregular. There are three main types of lie -

Longitudinal is where the head/buttocks are palpable at each end of the uterus Oblique lie is where the head/buttocks are palpabe in the iliac fossae Transverse lie is where the foetus is lying directly across the uterus

The presenting part is the part of the foetus which occupies the lower pole of the uterus. Warn the mother of discomfort and apply firm pressure at the lower pole of the uterus -

Cephalic presentation is suggested by a round presenting part Breech presentation is suggested by a broader, softer, less defined presenting part

Engagement is assessed by how much of the head can be felt in the abdomen. The head is engaged when the widest diameter has passed through the pelvic brim -

The station can be expressed as the number of fifths of the head palpable above the pelvic brim

The position of the foetus is the relation of the presenting part to the quadrants of the maternal pelvis. This is achieved by locating the back of the foetus to determine the position of the occiput relative to the birth canal Antenatal Care Antenatal care (ANC) is the complex of interventions that a pregnant woman receives from organised healthcare services -

This includes planning for pregnancy and extends into the neonatal and postpartum period (for the first 42 days/ 6 weeks)

The objective of ANC is to promote and maintain physical, mental, and social health of mother and baby through education. Other objectives include -

Detecting and managing complications Formulating birth plans Helping the mother to experience normal puerperium

NB: the first trimester = 1 – 12 weeks, the second = 13 – 27 weeks, and the third is 28 – term. Pre-Pregnancy Care Pre-pregnancy counselling is tailored to the specific patient, used to detect factors that may heighten perinatal risk. Key issues to determine include -

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Past medical history including: diabetes, mellitus, epilepsy, cardiac disease, haematological disorders o Diagnosis of these conditions can also occur as part of pre-pregnancy care o In women with pre-existing conditions, it is important to determine when may be a good time to conceive e.g. good BM control in diabetics Alcohol, smoking and drug history

This pre-pregnancy care is an opportunity to reinforce positive health messages such as advice on diet, smoking cessation, and alcohol and drug abstinence -

Pregnant women are also prescribed folic acid supplementation o 400mcg from pre-conception up to 12 weeks’ gestation is used in most patients o 5mg from pre-conception up to 12 weeks is recommended in previous neural tube defects and diabetics

Pregnancy testing is another key feature of pre-pregnancy care. There are many different forms of pregnancy testing; but they measure ß-HCG. ß-HCG is produced by the trophoblast cells of the embryo from day 6 post-fertilisation, and is detectable in the blood and urine from 6 – 12 days after fertilisation (when the embryo has implanted) -

Urine pregnancy tests can be taken any time after the first day of the missed period, these are sensitive at ~100 mIU Quantitative bloods tests can detect hCG levels as low as 1 mIU/mL o These are only performed in women where there is pain or an empty uterus on scanning

Antenatal Care The first visit to the community midwife (booking appointment) takes place at 1:50 at >45 years

There are two screening methods for Down’s syndrome, combining serum screening and USS screening (the integrated test)

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USS screening is performed at the booking scan (11 – 14 weeks), looking for increased nuchal translucency - Serum screening is performed from 10 – 14 weeks, checking for the following markers o PAPP-A, reduced o Beta-hCG, raised If the woman books later in pregnancy, the integrated test is not accurate and the quadruple test for serum markers is undertaken instead -

Beta-hCG, raised AFP, reduced uE3, reduced Inhibin-A, raised

Antenatal Diagnosis As antenatal screening simply suggests that the pregnancy is at high risk of a condition, a definitive diagnostic test should be offered to the woman Many techniques can be used -

Amniocentesis is an invasive procedure carried out at >15 weeks’ gestation. The risk of miscarriage is ~1% Chorionic villous sampling is an invasive procedure carried out at 11 – 13 weeks’ gestation. The risk of miscarriage is ~2% Fetoscopy uses endoscopic techniques to visualise the foetus allowing inspection, blood sampling, and possible intervention Cordocentesis (umbilical blood sampling) uses USS to obtain cells from the cord from >18 weeks’ gestation Maternal blood tests for foetal DNA are increasing in prevalence and sophistication Pre-implantation genetic diagnosis

These diagnostic techniques offer many benefits -

Reassurance Optimal obstetric management, intervention where possible, and counselling/preparation for neonatal management Termination of pregnancy

Alcohol and drug misuse in pregnancy is associated with maternal and foetal morbidity, alongside additional legal and environmental factors -

MDT involvement in these cases is key in their management e.g. GP, midwife, obstetrician, substance misuse service

All pregnant women should be asked about alcohol and drug use at the booking appointment, and referred where necessary -

Ask the woman what she is using, how often, by which route, and how much she is spending on the substance

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With the woman’s consent, check a urine specimen each visit to confirm or exclude the presence of illicit substances

Child protection issues in these cases are key, and referral to social services should be made where there are concerns Foetal Alcohol Spectrum Disorder Alcohol in pregnancy is associated with many adverse outcomes -

Infertility Early miscarriage Structural abnormalities Preterm labour IUGR Neurodevelopmental abnormalities

The effects on the foetus can be summarised as foetal alcohol syndrome, which has a spectrum of severity dependent on maternal alcohol intake. There are three main components to this -

Typical facial abnormalities o Microcephaly, flat philtrum, thin upper lip, low set ears IUGR o This persists with short stature into adulthood Neurodevelopmental abnormalities causing developmental delay, learning disability, and behavioural problems o Hyperactivity o Sleep and language delay

ASDs and VSDs are also common in these infants, alongside hearing and visual impairments. Opioids Opioids are also associated with many adverse effects -

Structural abnormalities IUGR Respiratory depression in the neonate SIDS Neonatal withdrawal syndrome Neurodevelopmental abnormalities

Stimulant and Sedative Drugs Sedative drugs are associated with neonatal withdrawal syndrome Stimulant drugs tend to have a more varied effect -

Early miscarriage Structural abnormalities Preterm labour

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Placental abruption IUGR Stillbirth SIDS

Termination of Pregnancy (TOP) TOP is a medically directed miscarriage Prior to TOP, it is important to counsel the patient appropriately on her options to ensure that she comes to the decision that she will least regret, as well as the methods of abortion available to her. If she chooses TOP, there are several recommended investigations -

USS to assess the pregnancy, including dating Screen for STIs, particularly chlamydia Discuss future contraceptive needs, including the insertion of IUCD at the time of TOP or starting a contraceptive pill the next day Check rhesus status, and give anti-D where negative Assess VTE risk

Antibiotic prophylaxis should be offered to all women undergoing TOP. This is usually with 1g metronidazole prior to abortion followed by a seven-day course of 100mg doxycycline BD. There are two main methods of TOP -

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Surgical is with vacuum aspiration or dilation and evacuation o Vacuum aspiration is suitable up to 14 weeks’ gestation o Dilation and evacuation is suitable from 14 – 24 weeks Medical TOP is with mifepristone followed by misoprostol o 20% Monochorionic o Twin-twin transfusion syndrome (TTTS) results from unequal blood distributionin the placenta due to vascular anastomosis. One twin is the donor, and become volume depleted and anaemic. The other twin is the recipient and becomes polycythaemic with polyhydramnios

Twin reverse arterial perfusion (TRAP sequence). This is rare, and occurs as one twin lacks an umbilical cord, therefore the other twin’s cardiovascular system is perfusion it through the placenta Monoamniotic o Cord entanglement o

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All multiple pregnancies are high risk pregnancies, and should have more frequent growth scans from 20 weeks. In general, if the first baby is in cephalic presentation, normal vaginal delivery is achievable.

Hypertension in Pregnancy Hypertensive disorders in pregnancy can be sub classified into those that are pre-existing, and those that are pregnancy induced -

Pregnancy-induced hypertension includes pre-eclampsia and gestational hypertension Pre-existing hypertension can be primary, or secondary to renal/endocrine disorders

There are natural alterations to blood pressure in pregnancy, due to the increased circulating volume and altered systemic vascular resistance -

Blood pressure will normally fall in the second trimester, rising back to normal by term

There is some degree of normal proteinuria in pregnancy, usually 40 Previous pregnancy >10 years ago BMI >35 Family history of pre-eclampsia Multiple pregnancy Hypertension or pre-eclampsia in a past pregnancy CKD Autoimmune disease Diabetes mellitus Chronic hypertension

Pre-Existing Hypertension Pre-existing hypertension is defined as a systolic blood pressure >140 and/or diastolic pressure >90 either pre-pregnancy or at booking (before 20 weeks) -

The general aim of managing these patients is to keep BP 1+ proteinuria is seen on urine dip, arrange for 24-hour urine collection to identify significant proteinuria Additional USS is recommended o 28 – 30 weeks and 32 – 34 week scans to assess foetal growth and amniotic fluid volume, as well as umbilical artery Doppler

Patients with underlying hypertension have a 6x increased risk of pre-eclampsia Gestational Hypertension Gestational hypertension is pregnancy-induced hypertension that develops after 20 weeks’ gestation -

This can be either transient, or chronic hypertension that persists into the latter half of the pregnancy

Severity of gestational hypertension is sub classified, this determines management -

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Mild = 140/90 – 149/99 o Check BP and proteinuria weekly Moderate = 150/100 – 159/109 o Check BP and proteinuria twice weekly o Start labetalol to keep SBP 160/110 o Admit to hospital and start labetalol to keep SBP 0.3g/24hr or PCR >30mg/nmol

There are several recognised risk factors for pre-eclampsia -

Nulliparity Previous or family history Older maternal age Maternal disease e.g. hypertension, diabetes, autoimmunity, renal disease, obesity Multiple pregnancy

The condition develops in two stages, and is due to placental factors -

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Stage 1 occurs before 20 weeks, and is asymptomatic. Incomplete trophoblastic invasion leads to reduced uteroplacental flow through the spiral arteries. This creates an exaggerated inflammatory response Stage 2 is where disease manifests. Inflammation damages endothelial cells, leading to vasoconstriction and increased vascular permeability o Vascular permeability results in oedema and proteinuria o Vasoconstriction causes hypertension, liver damage, deranged clotting, and eclampsia

Presentation Pre-eclampsia is usually asymptomatic, but can present with the following features -

Severe headache Blurred vision Severe epigastric pain and/or vomiting Oedema of the hands, feet, or face Clonus

Investigation and Management BP and urine dip indicate possible pre-eclampsia, and should be followed by urinalysis to exclude differentials/ confirm diagnosis

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MC&S 24-hour urine collection or PCR of single sample

At diagnosis there should be foetal monitoring is with USS to assess foetal growth and amniotic fluid volume, as well as uterine artery Doppler. CTG is also performed -

These investigations should not be repeated more than once per week

All women with pre-eclampsia should be admitted to hospital for full assessment of their condition, and monitoring of its progress. Management of disease is dependent on severity -

Mild disease is proteinuria with BP 140/90 – 149/99 o Monitor BP QDS o Twice weekly bloods: U&Es, FBC, LFTs - Moderate disease is proteinuria with BP 150/100 – 159/109 o Give antihypertensive to keep SBP QDS o Bloods three times weekly: U&Es, FBC, LFTs The only cure for pre-eclampsia is delivery of the placenta. There can usually be conservative management (without delivery of the baby) until at least 34 weeks, as long as there is haemodynamic stability, normal coagulation, and no foetal distress -

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Mild pre-eclampsia requires delivery by 37 weeks Moderate or severe requires delivery at 34 – 36 weeks, with steroids given where appropriate o For severe pre-eclampsia give IV magnesium sulphate ~24 hours before delivery If there are complications or foetal distress, there should be immediate delivery regardless of gestation

Delivery is usually caesarean before 34 weeks, or induced vaginal delivery at later gestation. Blood pressure should be monitored continuously, and pushing should be avoided if >160/110 at any time -

Fluid restriction (1ml/kg/hr) is recommended to reduce the risk of fluid overload in the intrapartum and postpartum periods Syntometrine should not be used to manage third stage as ergometrine increases blood pressure. Syntocinon is used as an alternative.

Post-natal care of pre-eclampsia is key, as disease may worsen in the first 24 hours post-delivery -

Measure LFTs, FBC, and U&Es at 48 - 72 hours, and repeat if abnormal Monitor fluid balance. If urine output is low, consider CVP monitoring Measure BP every 1 – 2 days for two weeks, reducing antihypertensives gradually as it falls. Treatment may be needed for several weeks Perform a urine dip at 6 weeks to ensure proteinuria has ceased

Complications Maternal complications are severe, and can lead to maternal death -

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Eclampsia CVA, usually haemorrhagic stroke HELLP o Haemolysis is suggested by dark urine, anaemia, and raised LDH o Elevated liver enzymes are suggested by deranged LFTs and clotting o Low platelet count DIC Hepatorenal failure Pulmonary oedema and ARDS

Foetal complications can lead to foetal death -

IUGR Preterm birth Placental abruption Hypoxia

Eclampsia Eclampsia is the occurrence of seizures superimposed on pre-eclampsia. This requires urgent management -

Give a loading dose of 4g magnesium sulphate, following by an infusion of 1g/hr for 24 hours Give IV labetalol to reduce BP Deliver the baby as soon as the mother is stable. Do not attempt delivery before, even if there is foetal distress

Common Medical Problems in Pregnancy Anaemia In pregnancy the plasma volume increases disproportiona...