Obstetrics

There are several infections that can be transmitted from the mother to the fetus. This can be dangerous as the fetus does not have a fully developed immune system and is more susceptible to serious complications. – Methods of vertical transmission include transplacental (across placenta in utero), during childbirth (due to contact between maternal and foetal body fluids) and breastfeeding.   The  pathogens which can be transmitted from mother to fetus can be remembered by acronym TORCH:   Chorioamnionitis This describes inflammation of the foetal membranes (chorion and amnion) usually due to bacterial infection. – The major risk factor is

In the uterus, there are 3 variables that we monitor concerning the baby’s position.   Lie: – This is the relationship between the long axis of the fetus and that of the mother – It can be longitudinal, transverse or oblique   Presentation: – This describes the part of the fetus that first enters the maternal pelvis – Can be cephalic vertex (headfirst), breech, shoulder, face and brow   Position: – This describes the position of the foetal head as it exits the birth canal – Can be occipito-anterior (ideal), occipito-posterior or occipito-transverse   Abnormal lies, presentations and positions all

Post-partum Haemorrhage (PPH) This is defined as blood loss of >500mls after delivery and it is divided into two subtypes:   Primary: – This is blood loss which occurs within 24 hours of delivery: – The causes can be remembered by thinking of the 4 T’s   Causes: Tone (uterine atony most commonly) Trauma (large baby) Thrombus (clots) Tissue (fibroids) – In addition, it can be caused by abnormalities of the placenta (placenta previa/accrete)   Management: – 1st line –> Apply bimanual compression (pressure aims to compress uterine arteries) with fundal massage   – 2nd line is medical management –>

Gestational Thrombocytopaenia A condition which causes transiently low platelet levels in pregnancy, not associated with maternal/fetus risks. – It occurs due to plasma dilution as well as decreased production of platelets during pregnancy. – The problem is that it is similar to immune thrombocytopenia (ITP) which can lead to several problems – Therefore, one must rule out ITP as it can affect both the mother and fetus (as antibodies cross the placenta)   Symptoms – This is usually asymptomatic – Gives isolated decrease in platelet levels which return to normal levels after pregnancy – Woman has no medical history of

Pregnancy-induced hypertension This is defined as having a raised blood pressure which occurs after the 20th week of pregnancy without proteinuria. – If a woman has hypertension before, then this is counted as pre-existing hypertension. Whereas, if she develops other symptoms like proteinuria and oedema, this points to a diagnosis of pre-eclampsia – Gestational hypertension resolves after birth, but women have higher risk of pre-eclampsia in the next pregnancy – The major risk to watch out for is progression to pre-eclampsia (High BP with proteinuria)   The hypertension is defined as two separate readings confirming either: – Systolic >140mmHg or

Post-partum Haemorrhage (PPH) This is defined as blood loss of >500mls after delivery and it is divided into two subtypes:   Primary: – This is blood loss which occurs within 24 hours of delivery: – The causes can be remembered by thinking of the 4 T’s   Causes: Tone (uterine atony most commonly) Trauma (large baby) Thrombus (clots) Tissue (fibroids) – In addition, it can be caused by abnormalities of the placenta (placenta previa/accrete)   Management: – 1st line –> Apply bimanual compression (pressure aims to compress uterine arteries) with fundal massage   – 2nd line is medical management –>

Placenta Accreta This is a condition where the placenta attaches directly to the myometrium rather than the endometrium. – This is a problem as it gives a very high risk of heavy bleeding at time of vaginal delivery.   There are 3 different types of placenta accreta depending on the degree of invasion: i) Accreta –> Chorionic villi attach to the myometrium but will not invade into this layer ii) Increta –> Chorionic villi invade into the myometrium, the muscular layer of the uterus iii) Percreta –> Chorionic villi invade through the myometrium into the perimetrium   Risk factors: Anything which damages the lining of the

Placenta Accreta This is a condition where the placenta attaches directly to the myometrium rather than the endometrium. – This is a problem as it gives a very high risk of heavy bleeding at time of vaginal delivery.   There are 3 different types of placenta accreta depending on the degree of invasion: i) Accreta –> Chorionic villi attach to the myometrium but will not invade into this layer ii) Increta –> Chorionic villi invade into the myometrium, the muscular layer of the uterus iii) Percreta –> Chorionic villi invade through the myometrium into the perimetrium   Risk factors: Anything which damages the lining of the

Hyperemesis Gravidarum This is a condition which causes nausea and vomiting in pregnant women and accompanied with weight loss – Nausea and vomiting is common during pregnancy, and so the term hyperemesis gravidarum is only used if this leads to complications like dehydration or >5% weight loss – This condition is experiences in the first trimester and usually resolves by week 20 – It is believed to be due to raised beta-hCG sensitizing the vomiting centre – Severe vomiting leads to dehydration and electrolyte abnormalities in the mother   Risk factors: This is anything which leads to raised b-hCG –

Hyperemesis Gravidarum This is a condition which causes nausea and vomiting in pregnant women and accompanied with weight loss – Nausea and vomiting is common during pregnancy, and so the term hyperemesis gravidarum is only used if this leads to complications like dehydration or >5% weight loss – This condition is experiences in the first trimester and usually resolves by week 20 – It is believed to be due to raised beta-hCG sensitizing the vomiting centre – Severe vomiting leads to dehydration and electrolyte abnormalities in the mother   Risk factors: This is anything which leads to raised b-hCG –

In the uterus, there are 3 variables that we monitor concerning the baby’s position.   Lie: – This is the relationship between the long axis of the fetus and that of the mother – It can be longitudinal, transverse or oblique   Presentation: – This describes the part of the fetus that first enters the maternal pelvis – Can be cephalic vertex (headfirst), breech, shoulder, face and brow   Position: – This describes the position of the foetal head as it exits the birth canal – Can be occipito-anterior (ideal), occipito-posterior or occipito-transverse   Abnormal lies, presentations and positions all

Bleeding in the first trimester of pregnancy is not an uncommon event but is a source of anxiety for mothers. – The reasons for this can range from idiopathic to serious conditions like an ectopic pregnancy. – In addition, it can also be due to gynaecological conditions like ectropion, trauma and polyps   If a woman has bleeding in the first trimester, management depends on the gestational age and her symptoms: If <6 weeks gestation: – Expectant management. Advise woman to repeat pregnancy test after 7-10 days – If this is positive then return to the clinic – If the

Hyperemesis Gravidarum This is a condition which causes nausea and vomiting in pregnant women and accompanied with weight loss – Nausea and vomiting is common during pregnancy, and so the term hyperemesis gravidarum is only used if this leads to complications like dehydration or >5% weight loss – This condition is experiences in the first trimester and usually resolves by week 20 – It is believed to be due to raised beta-hCG sensitizing the vomiting centre – Severe vomiting leads to dehydration and electrolyte abnormalities in the mother   Risk factors: This is anything which leads to raised b-hCG –

Pregnancy-induced hypertension This is defined as having a raised blood pressure which occurs after the 20th week of pregnancy without proteinuria. – If a woman has hypertension before, then this is counted as pre-existing hypertension. Whereas, if she develops other symptoms like proteinuria and oedema, this points to a diagnosis of pre-eclampsia – Gestational hypertension resolves after birth, but women have higher risk of pre-eclampsia in the next pregnancy – The major risk to watch out for is progression to pre-eclampsia (High BP with proteinuria)   The hypertension is defined as two separate readings confirming either: – Systolic >140mmHg or

This is the second most common medical complication in pregnancy after high blood pressure. – It is defined as any degree of glucose intolerance with onset/first recognition during pregnancy – In pregnancy, there is progressive insulin resistance which means a higher volume of insulin is needed to respond to a normal level of blood glucose – A woman with a borderline pancreatic reserve is unable to respond to the increased insulin requirement – This results in transient hyperglycaemia giving gestational diabetes – After the pregnancy, insulin resistance falls and the hyperglycaemia usually resolves – However, whilst it is usually asymptomatic

After giving birth, several women experience some symptoms, which can take a while to return to normal: – Urinary: Pain when passing urine and stress incontinence – GI: Inability to pass stool for a few days after birth and increased risk of haemorrhoids – Genital: Pass Lochia (this is vaginal discharge containing blood, mucous and uterine tissue Can continue for 6 weeks after birth and slowly turns brownish colour before finally stopping   However, there are situation where women experience longer term, more serious symptoms after pregnancy    Postpartum Thyroiditis This is a condition where there is dysfunction of the

Post-partum Haemorrhage (PPH) This is defined as blood loss of >500mls after delivery and it is divided into two subtypes:   Primary: – This is blood loss which occurs within 24 hours of delivery: – The causes can be remembered by thinking of the 4 T’s   Causes: Tone (uterine atony most commonly) Trauma (large baby) Thrombus (clots) Tissue (fibroids) – In addition, it can be caused by abnormalities of the placenta (placenta previa/accrete)   Management: – 1st line –> Apply bimanual compression (pressure aims to compress uterine arteries) with fundal massage   – 2nd line is medical management –>

Oligohydramnios This is the term used to describe an abnormally low level of amniotic fluid during pregnancy – It is characterised by having less than <500ml at 32-36 weeks and amniotic fluid index (AFI) <5th percentile – It can lead to abnormal foetal presentations and underdevelopment of foetal parts   Causes: – Low production of foetal urine –> Renal agenesis (Potter’s syndrome), dysplastic kidney, obstructive uropathy – Poor Placental diffusion –> Pre-eclampsia – Leakage of amniotic fluid –> Premature rupture of membranes   Complications: – Abnormal lie and development – Poor respiratory development –> amniotic fluid is needed for maturation

The probability of having twins is just under 1% which means that it is not very uncommon. – There are two main types of twins, according to whether one or two egg cells has been fertilised.   Monozygotic (MZ) twins This describes twins which develop from a single ovum which then divides into 2 identical embryos – In monozygotic pregnancies, there are various ways in which the amniotic sac and placenta are shared. i) Dichorionic, diamniotic (DCDA) Each twin has its own individual amniotic sac and placenta – About 1/3 of monozygotic pregnancies   ii) Monochorionic, diamniotic (MCDA): These twins

In the uterus, there are 3 variables that we monitor concerning the baby’s position.   Lie: – This is the relationship between the long axis of the fetus and that of the mother – It can be longitudinal, transverse or oblique   Presentation: – This describes the part of the fetus that first enters the maternal pelvis – Can be cephalic vertex (headfirst), breech, shoulder, face and brow   Position: – This describes the position of the foetal head as it exits the birth canal – Can be occipito-anterior (ideal), occipito-posterior or occipito-transverse   Abnormal lies, presentations and positions all

There are several infections that can be transmitted from the mother to the fetus. This can be dangerous as the fetus does not have a fully developed immune system and is more susceptible to serious complications. – Methods of vertical transmission include transplacental (across placenta in utero), during childbirth (due to contact between maternal and foetal body fluids) and breastfeeding.   The  pathogens which can be transmitted from mother to fetus can be remembered by acronym TORCH:   Chorioamnionitis This describes inflammation of the foetal membranes (chorion and amnion) usually due to bacterial infection. – The major risk factor is

Having chronic diseases and taking medication can increase the risk of harm to the mother and the fetus.   Diabetes Mellitus in Pregnant Women Like gestational diabetes, uncontrolled diabetes is dangerous in pregnant woman – This is because the placenta secretes cortisol and progesterone which increases insulin resistance – This leads to complications for the mother as well as for the fetus. – Babies can be large (or small) for gestational age (macrosomia) which can make delivery difficult – In addition, there is a higher risk of the baby being born with hypoglycaemia, jaundice and polycythaemia   Management: This involves managing

Gestational Thrombocytopaenia A condition which causes transiently low platelet levels in pregnancy, not associated with maternal/fetus risks. – It occurs due to plasma dilution as well as decreased production of platelets during pregnancy. – The problem is that it is similar to immune thrombocytopenia (ITP) which can lead to several problems – Therefore, one must rule out ITP as it can affect both the mother and fetus (as antibodies cross the placenta)   Symptoms – This is usually asymptomatic – Gives isolated decrease in platelet levels which return to normal levels after pregnancy – Woman has no medical history of

Placenta Accreta This is a condition where the placenta attaches directly to the myometrium rather than the endometrium. – This is a problem as it gives a very high risk of heavy bleeding at time of vaginal delivery.   There are 3 different types of placenta accreta depending on the degree of invasion: i) Accreta –> Chorionic villi attach to the myometrium but will not invade into this layer ii) Increta –> Chorionic villi invade into the myometrium, the muscular layer of the uterus iii) Percreta –> Chorionic villi invade through the myometrium into the perimetrium   Risk factors: Anything which damages the lining of the

Pregnancy-induced hypertension This is defined as having a raised blood pressure which occurs after the 20th week of pregnancy without proteinuria. – If a woman has hypertension before, then this is counted as pre-existing hypertension. Whereas, if she develops other symptoms like proteinuria and oedema, this points to a diagnosis of pre-eclampsia – Gestational hypertension resolves after birth, but women have higher risk of pre-eclampsia in the next pregnancy – The major risk to watch out for is progression to pre-eclampsia (High BP with proteinuria)   The hypertension is defined as two separate readings confirming either: – Systolic >140mmHg or

This is the second most common medical complication in pregnancy after high blood pressure. – It is defined as any degree of glucose intolerance with onset/first recognition during pregnancy – In pregnancy, there is progressive insulin resistance which means a higher volume of insulin is needed to respond to a normal level of blood glucose – A woman with a borderline pancreatic reserve is unable to respond to the increased insulin requirement – This results in transient hyperglycaemia giving gestational diabetes – After the pregnancy, insulin resistance falls and the hyperglycaemia usually resolves – However, whilst it is usually asymptomatic

Hyperemesis Gravidarum This is a condition which causes nausea and vomiting in pregnant women and accompanied with weight loss – Nausea and vomiting is common during pregnancy, and so the term hyperemesis gravidarum is only used if this leads to complications like dehydration or >5% weight loss – This condition is experiences in the first trimester and usually resolves by week 20 – It is believed to be due to raised beta-hCG sensitizing the vomiting centre – Severe vomiting leads to dehydration and electrolyte abnormalities in the mother   Risk factors: This is anything which leads to raised b-hCG –

Bleeding in the first trimester of pregnancy is not an uncommon event but is a source of anxiety for mothers. – The reasons for this can range from idiopathic to serious conditions like an ectopic pregnancy. – In addition, it can also be due to gynaecological conditions like ectropion, trauma and polyps   If a woman has bleeding in the first trimester, management depends on the gestational age and her symptoms: If <6 weeks gestation: – Expectant management. Advise woman to repeat pregnancy test after 7-10 days – If this is positive then return to the clinic – If the

When a woman suspects that she is pregnant, there are a number of following tests and appointments. – Clinical signs of that suggest pregnancy are amenorrhoea, nausea/vomiting, breast enlargement and increased urinary frequency and fatigue. – For uncomplicated pregnancies, NICE recommend women with first pregnancy have 10 antenatal visits. – For subsequent pregnancies, they only need 7 antenatal visits and do not need to be seen by a consultant.    Usual route of pregnancy   i) Positive pregnancy test at home: Women suspecting pregnancy take a urine dipstick pregnancy test   ii) GP: If positive, women book an appointment with

During pregnancy there is also development of the breast tissue to prepare for breastfeeding. – After delivery of the placenta, the low progesterone and high prolactin stimulate milk secretion – Prolactin –> stimulates lactogenesis and disrupts the pulsatile GnRH secretion (natural contraception) – Oxytocin –> stimulates milk ejection from the breast as well as uterine contractions   Milk contains all the nutrients the infant needs (except vitamin D and K) up till 6 months of age. – It is divided into the colostrum (first milk produced) and mature milk:   Colostrum: – First milk produced that is rich in proteins

Labour can be defined as the onset of regular and painful contractions associated with cervical dilation and descent of the presenting part. – It involves shedding of the cervical mucus plug, rupture of the amniotic sac and uterine contractions.   The shortening of the uterine myocytes causing Braxton-Hicks contractions is key to labour: – [Ca2+]i increases by influx through Ca2+ channels and by release from the SR – Ca2+ activates calmodulin (CAM) –> calmodulin activates myosin light chain kinase (MLCK) – MLCK generates ATP for contraction of the filaments Labour is divided into 3 stages:   Stage 1: This describes the

To support the foetus, the mother must undergo several physiological changes to the different organ systems:   Cardiovascular: There are several changes to the cardiovascular system, affecting a number of key variables:   i) Blood Volume: – Blood volume increases in pregnancy due to activation of renin-angiotensin system   ii) Cardiac output: – This increases in pregnancy due to increase in heart rate and stroke volume – This is because heart undergoes eccentric hypertrophy during pregnancy – This displaces the apex beat upwards and gives an innocent systolic murmur.   iii) Blood pressure: – Despite the increase in cardiac output,

The embryo enters the uterus 4 days after fertilisation and transitions from a morula to a blastocyst. – It then undergoes hatching where the outer zona pellucida is removed allowing it to attach to the endometrium. – It undergoes invasive interstitial implantation, where the cells of the blastocyst invade into the uterine lining. – This invasion, and the merging of the syncitiotrophoblasts and endometrial cells allows the placenta to form.    The placenta is a discoid organ which is composed of two plates: i.) Chorionic plate –> faces the foetus and has the umbilical cord attached ii.) Basal plate –>

A pregnancy is dated by the weeks of gestation from the first day of the mother’s last menstrual period (LMP) – Embryonic age = Gestational age – 2 weeks (as fertilization occurs about 2 weeks after the LMP)   In order to record how many times a woman has been pregnant, the gravida/parity/abortus system is used: Gravida = the number of times a woman has been pregnant, regardless of the pregnancy outcome Parity = The number of pregnancies which have survived > 20 weeks (including live births and stillbirths) Abortus = the number of pregnancies that were lost at a gestational age of

Introduction Pre-eclampsia is a complication of pregnancy characterised by hypertension and proteinuria with or without oedema. It is a systemic disease whose exact aetiology is still not fully understood, though uteroplacental dysfunction and widespread maternal endothelial dysfunction is seen. It is a significant cause of maternal morbidity and mortality. Severe cases may result in seizures (eclampsia), multi-organ failure (in particular the liver and kidneys) and significant coagulopathy. There are a number of terms to be aware of which may be variably defined. Here we present the definitions from the International Society for the Study of Hypertension in Pregnancy (ISSHP), The classification,

Introduction Obstetric haemorrhage, which includes both antepartum and postpartum haemorrhage, is the leading cause of maternal death worldwide. Within the UK, maternal death from obstetric haemorrhage is uncommon, but still causes approximately 7 deaths per year. Postpartum haemorrhage refers to vaginal bleeding up to 12 weeks following delivery. Prompt recognition and management is key to good outcomes. It should be remembered that earlier antepartum haemorrhage can reduce a patient’s physiological reserve and ability to compensate for bleeding in the postpartum period. Classification Postpartum haemorrhage (PPH) can be classified as either primary or secondary. Primary PPH: is defined as vaginal bleeding that occurs from

Introduction In 2018 an estimated 731,213 births took place in the UK according to figures from the ONS. In healthy women, with a singleton pregnancy, who have not suffered from complications during this or previous pregnancies, a normal labour can often be expected. As NICE advise, women, if healthy and low risk, should be supported in having their birth at home, in a midwifery unit or an obstetric unit in line with their preference. First stage Regular contractions herald the arrival of the first stage of pregnancy and continues until the cervix is fully dilated. Aspects of care A partogram – graphic

Overview Intrahepatic cholestasis of pregnancy is a liver disease unique to pregnancy that is characterised by pruritus and elevated bile acids. Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-associated liver disease. It is characterised by pruritus (i.e. itching), elevated bile acids, and variable elevations in liver function tests (e.g. ALT/AST). It is due to cholestasis (i.e. decreased bile flow) and classically occurs in the late second or third trimester. ICP is important to recognise because it is associated with an increased risk of fetal demise and stillbirth, particularly when the bile acid concentration is ≥ 100 micromol/L. Pregnancy-associated liver disease

Overview Hyperemesis gravidarum refers to severe nausea and vomiting in pregnancy. Nausea and vomiting in pregnancy affects around 80-90% of women. In its more severe form it is referred to as hyperemesis gravidarum. These terms can be defined as follows: Nausea and vomiting in pregnancy: refers to nausea and vomiting with onset in the first trimester when other causes are excluded. Symptoms tend to develop between 4 – 7 weeks and resolve by 20 weeks in most women. Hyperemesis gravidarum: this is diagnosed in patients with protracted nausea and vomiting and the following triad: > 5% pre-pregnancy weight loss Dehydration Electrolyte imbalance Epidemiology

Introduction Caesarean section is an operation in which a baby is delivered via an abdominal incision. The caesarean section, or procedures similar to it, have been described for thousands of years in many of the world’s cultures. To this day the origins of the term caesarean are disputed. A caesarean section is a birthing option that in some circumstances reduces risk to the mother, baby or both. Many women also choose to opt for a caesarean section for personal reasons having weighed it up against a vaginal delivery. In total, around 25-30% of births in the UK are via caesarean section. The following

Overview The APGAR score is conducted in term infants as an assessment of clinical status immediately following birth. It was developed by an American anaesthetist, Dr Virginia Apgar, in 1952 as a quick assessment of clinical status. For those interested, a reprint of the original publication can be found here. The score has five components; heart rate, respiratory effort, muscle tone, reflex irritability, and colour. Each receives a score from 0 to 2 with a maximum score of 10. Score The score is calculated at one and five minutes after cleaning and drying the baby in a warm towel. If necessary it may be repeated

Introduction Obstetric haemorrhage, which includes both antepartum and postpartum haemorrhage, is the leading cause of maternal death worldwide. Within the UK, maternal death from obstetric haemorrhage is uncommon, but it still causes approximately 4-7 deaths per year. Obstetric haemorrhage is a common cause of both maternal and neonatal morbidity. Antepartum haemorrhage (APH) complicates approximately 3-5% of all pregnancies. It is estimated that up to 20% of very preterm babies are born in association with an APH. APH is defined as any vaginal bleeding from 24 weeks gestation until delivery. Bleeding that occurs within the first 24 weeks of gestation is known