ANTEPARTUM HAEMORRHAGE == bleeding from genital tract after 24 weeks gestation

History - Painful (abruption) or Painless Causes

(previa)
- Amount of blood loss
bright/dark, clots, teaspoon
etc.
- Provoked vs unprovoked
- Abdominal trauma
- Post-coital bleeding
- Rupture of membranes
(abruption or vasa praevia)
- Uterine contractions
placental abruption or onset
of labour
- Fetal movements
Symptoms of hypovolemic
shock/anaemia (booking
Hb/last Hb, BP)
History of low-lying placenta
Previous antepartum
haemorrhage
Previous C-section or uterine
surgery (risk factors for
placenta praevia)
Smoking, cocaine (placental
abruption)
Meds Galfer, LMWH, TEDS
stocking
Rhesus status anti-D
Exam Vitals
Pallor
Uterine tenderness, palpable
contractions
Fetal lie and presentation
Doptone
Pelvic exam is done only if
placenta praevia is outruled
Onset of labor
Undetermined origin
Placental abruption
Placenta previa
Uterine rupture
Vasa previa
Lower genital tract lesion (Cervical
ectropion, cervical polyp, cervical Ca,
vaginitis)
Coagulopathy
RF for each cause
Vasa praevia rupture painless moderate
vaginal bleed emergency CS
Investigations (ask in history)
- Bloods FBC, coag, DIC screen
(fibrinogen, d-dimer), GXM (4 units
blood), U+E
- Kleihauer test if rhesus negative
- Ultrasound placenta location,
assessment of fetal wellbeing,
determine fetal lie and presentation
(guide mode of delivery)
- CTG
Management
- ABC
- Monitor maternal and fetal well-being
- Anti-D Ig
- Iron if Hb low
- Consider delivery at 38weeks or sooner
if bleeding ongoing
- Steroids if <34 weeks
- Magnesium sulphate
- Anticipate PPH prevent hypothermia,
hypocalcemia
 PLACENTA PRAEVIA == placenta that is partially/completely located in lower uterine segment
History Presenting complaint RF
intermittent painless bleed? (as - High parity
above), abnormal scan? - Advanced maternal age
Ask risk factors - Multiple pregnancy
Ask what results of scan - IVF
- Should have placental localising - Previous placenta praevia, CS, ERPC,
scan intrauterine surgery, perforation
- Can be anterior/posterior - Smoking, cocaine
Rhesus status any Anti-D - Use of ART
Complications
- Uncontrolled haemorrhage antenatal
or postpartum
- Placental abruption
Exam Breech presentation + transverse - DIC with heavy bleeding and placental
lie abruption
Fetal head is not - Fetal malpresentation
engaged/malpresentation/high - IUGR, IUD
presenting part - Preterm delivery
- PROM
Investigations
US
CTG, FBC, Coag crossmatch if bleeding
Management
ABC + maternal and fetal monitoring
If asymptomatic, not in labour, treat
anemia, anti-D, consider discharge
Elective CS 37-38 weeks
Symptomatic admit + steroids
(<34weeks), Anti-D
Emergency stabilize and induce labour
PLACENTAL ABRUPTION == separation of part or all of the placenta before delivery after 24 weeks
History Unexplained APH - Revealed/Concealed/Mixed
Painful bleeding Complications
Uterine tenderness + - Fetomaternal haemorrhage
contractions - PPH
Severe hard abdomen - DIC
- Renal Failure
Idiopathic, RF include:
- Pregnancy specific
o IUGR
o Pre-eclampsia/HTN
o History of previous placental abruption
o Multiparity
o Previous CS
Exam Abnormal CTG o Advanced maternal age
o External cephalic version
o Sudden uterine decompression following
membrane rupture in polyhydramnios or
multiple pregnancy
- Pregnancy non-specific
o AI dz
o Smoking
o Cocaine
o Trauma
Mx
Resus, crossmatch 6-10u, steroids, anti-D
Closely monitor
Deliver if fetal distress/>37weeks

Pre-existing HTN Pregnancy induced HTN

Serum Creatine, U/E, urate, LFT, urinalysis New BP ?
(blood, protein glucose), 24h urinary Check booking BP, and recheck BP
protine/creatinine clearance Admit patient
Renal US MSU urinalysis -- 1+ = 0.3g/l, 2+ = 1g/l, 3+
Autoantibody screen = 3g/l
ECG/ECHO 24h urine collection
Is this primary or secondary HTN PET bloods: FBC, U/E, LFT, LDH, uric acid +
coag in severe
Fluid restrict 80ml/hr
STOP ACEi
1. Start labetalol from 12 weeks
2. Review every 2 weeks in OPD with serial
growth scan + BP profile
3. Check BP and urine every week
4. Deliver at 38 weeks
5. After delivery, do full workup -- Renal
artery scan, ECHO
PRE-ECLAMPSIA == hypertension, proteinuria and edema
History Presenting complaint
symptomatic/asymptomatic
- Edema, weight gain
- Abdominal pain epigastric pain
(hepatic ischaemia/necrosis)
- Headache, visual disturbances
- Oliguria, anuria
- Shortness of breath
- Hemorrhagic manifestations
Assess for complications -- PV bleed
placental abruption
Fetal movements
Current pregnancy
proteinuria (dipstick? 24h urine -
collection?), HTN, fetal growth
scan results
PMHx HTN, diabetes, chronic
renal disease, autoimmune
disease
History of gestational HTN or
pre-eclampsia
Family history
When to deliver?
Exam - Weight gain and edema
(periorbital, limbs)
- HTN
- Proteinuria
- Hyper-reflexia
- Oliguria, anuria AKI
- SFH small for dates
- Uterine tenderness
- Fetal lie and presentation
induction of labor
- Doptone
When BP >140/90 after 20 weeks in the
absence of proteinuria
Worry about IUGR and PET
Management
1. Admit to monitor BP
2. Start antihypertensive - labetalol 200mg
PO Q12
3. Baseline US for baby
4. Weekly OPD monitoring - BP and urine
5. Serial growth scans every 2 weeks
6. Deliver at 38 weeks
RF
- Nulliparity
- Advanced maternal age
- History of pregnancy-induced HTN,
or pre-eclampsia
- Pre-existing HTN, DM, obesity, CKD,
thrombophilia, AI disease
- Family history
- Multiple gestation
- Molar pregnancy
Complications
- Maternal: DIC, stroke, liver
impairment, AKI, ARDS
FEtal: IUGR, prematurity, IUD,
oligohydramnios, placental
abruption
Management
ABC
Bloods
- FBC (anaemia, thrombocytopenia)
- U+E (raised serum uric acid,
creatinine)
- LFT (raised AST and ALT)
- Coag
US fetal biometry (IUGR), lie and
presentation, liquor, Doppler
24h urine and 4hrly obs (BP, proteinuria,
weight, I/O, fetal HR and movement)
Treat hypertension labetalol,
hydralazine
Make sure no thromboembolic disease
Renal dialysis
Plan induction at 34 weeks
Corticosteroids + MgSO4
If eclamptic seizure
ABC, investigations, IV labetalol 40mg,
IVMgSO4 4g bolus over 5-10 minutes,
catheter, steroids, delivery
Subsequent pregnancies
 Aspirin 75mg, Calcium, weight loss

PPROM == rupture of membranes before labour <37 weeks

History PC Complications: Prematurity, Sepsis/infection,
- Provoked/unprovoked oligohydramnios Pulmonary hypoplasia,
- Amount of fluid prolapse, placental abruption
gush/dribbling Diagnosis
- Duration 1. Maternal history
- Color 2. Sterile speculum exam -- pooling of liquor
- Odour in the posterior fornix, TRO cord prolapse
- TRO urinary 3. US
incontinence, any 4. Amnisure -- rapid immunoassay
LUTS Other Ix
- how long ago - CTG fetal tachycardia
- Associated symptoms - Ultrasound liquor volume, growth scan
o Pain, chills - Bloods FBC (leucocytosis), coag, GXM, U+E,
(chorioamnionitis) CRP, blood culture
o Contractions - Urine dipstick/urinalysis, HVS, amniotic fluid
(preterm labour) microscopy and culture (local infection
o Fever increases the risk of a PPROM)
o Vaginal discharge Management
o Bleeding?? 1. Admit
- Fetal movements 2. High vaginal swab (alternate day/weekly)
How was it confirmed? 3. FBC, CRP, US (alternate day/weekly)
Speculum exam, amnisure, 4. CTG
CTG 5. Close monitoring every 4h - maternal
- Swabs done? pulse, maternal temperature, fetal heart
- US normal liquor rate
volume? Size and 6. Give steroids if between 24-34 weeks (UK
presentation guidelines if <39 weeks by CS)
- Antibiotics 7. Give Anti-D
- Any steroids already? 8. PO erythromycin 250mg QDS for 10 days
Current symptoms? from 20 weeks (prophylaxis) only if no
- Odor, pain etc. chorioamnionitis or sepsis, + penicillin G if
GBS+
Delivery plans 9. If chorioamnionitis suspected -- Septic
screen + IV benzylpen + gent + metro and
deliver fetus
Tocolytics should not be used
Exam Vitals fever, tachy 0. OPD select few. After 72h
Uterine tenderness, 1. Delivery
SFH small for dates? a. Deliver if signs of infection/fetal
Fetal lie, presentation, distress
engagement
 b. Considered at 34 weeks, but many
units deliver at 37 weeks
Must say abdomen soft, non- c. Induce if >36 weeks syntocin
tender d. But if previous CS/contraindications
CS is more advisable, trial of labor
then CS / CS straight

PRETERM LABOUR == Regular painful contractions a/w cervical changes between 24-36+6 weeks
History PC RF
- Number of - Maternal: extreme age, lower SES, medical illness,
contractions, what high Hb, smoking, low BMI
cervical changes - Obstetric: previous preterm/miscarriage, short
Ask RF interpregnancy interval, PPROM, APH, HTN, pre-
Any ROM eclampsia, DM, male gender, genital tract
fetal lie and infection, multiple pregnancies, uterine
presentation abnormalities, APH, polyhydramnios, cervical
Any corticosteroids incompetence, LLETZ/cone biopsy
taken already Complications: Infection, abruption, cord prolapse,
cord compression, prematurity, malpresentation, IUD
Investigations
- Vaginal exam if no ROM
Exam Vitals, any signs of - FBC, crossmatch, coag, U/E
infection - Urine culture, HVS
Fetal lie and - Fetal fibronectin testing
presentation - CTG and US - confirm presentation, cervical length
(TVS)
Management
- Admit and monitor vitals and CTG
- Antibiotic prophylaxis ampicillin/erythromycin
- Corticosteroids (<34wks) IM dexamethasone 12
mg x 2 doses 24 hoursly or 6mg x 4 doses 12
hourly
- +/- tocolytics
- Delivery - NVD

Indications why induce?
Fetal
- Prolonged pregnancy
- Suspected IUGR
- Fetal compromise
Maternal
- Pre-eclcampsia, HTN
- DM
- Obstetric cholestasis
PROM
APH stable
Chorioamnionitis
INDUCTION OF LABOUR
Contraindications Complications
- Placenta praevia, vasa praevia - Risk of
- Malpresentation / abnormal lie instrumental
- Acute fetal compromise delivery/CS
- Pelvic obstruction - Hyperstimulation
- Anyn contraindication to VBAC may cause fetal
history of classical CS, previous distress, rarely
2CS, significant uterine surgery, uterine rupture
previous uterine rupture - Cord prolapse
- Active genital herpes (ARM)
- PPH
- Chorioamnionitis
Multiple gestation
IUD

IUGR/SGA
History - Medical history Causes
- Medications - Placental insufficiency smoking, pre-
- Social history: smoking, eclampsia, DM, other chronic disease
alcohol, drugs - Fetal causes: congenital/chromosomal
- Fx: parents BW - Congenital infection
- Obs history: - Wrong dates
o previous IUGR - Constitutional
o Parity Complications
o Previous BW - IUD
o SVD/CS - Preterm delivery prematurity
Course of pregnancy Investigations
- Trimester 1 US and LMP for - Screen with serial SFH
EDD - US biometry, liquor volume, doppler
- Anomaly scan, any - Uterine artery bilateral notching
amniocentesis, CVS - Umbilical artery absent or reversed
- Booking bloods serology, end-diastolic flow
infection - MCA artery increased end-diastolic
- Previous SFH normal flow velocity
- Fetal movements Management
- Prenatal testing (HARMONY - Lifestyle changes
>10 weeks ) - Antenatal: Close monitoring, Serial
- Weight gain biometry every 1/2 weeks
- HTN, proteinuria, Gestational - Delivery at 37-38 weeks (earlier if AEDF,
diabetes REDF)
- Anemia (iron supplements) - Postnatal: examine for congenital
Exam BP, proteinuria anomalies, manage hypoglycaemia,
SFH hypothermia and respiratory distress
Liquor volume
 UNSTABLE LIE = repeatedly changing fetal lie and presentation in a 24 hour period >36 weeks
History Risk factors (history)
- High parity
- Polyhydramnios
a. GDM?
b. Weight
- Oligohydramnios
- Macrosomia
- Multiple pregnancy
- Placenta previa ask
about placenta location
- Pelvic tumors
- Uterine deformities
- Fetal anomaly tumours
of the neck or sacrum,
hydrocephaly, abdominal
distension ask about
anatomy scan
Exam Lie and presentation
Polyhydramnios?
Increased SFH?
Difficult to feel parts?
Pelvic exam shape, tumors and
fibroids
Complications
- Cord prolapse esp with transverse
or oblique lie (after ROM)
- Fetal distress/hypoxia
- Obstructed labour birth trauma
- Uterine rupture
- PPH
Management
- No action is <37 weeks
- Admit if membranes rupture/labour
- If SROM occurs, perform vaginal
examination to exclude cord prolapse
- Elective admission to hospital after 37
weeks daily observation of fetal lie
and presentation
External cephalic version to
longitudinal lie followed by artificial
rupture of membranes (NB cord
prolapse, placental abruption) and
oxytocin infusion
Give Anti-D Ig before procedure
- If lie cannot be corrected, do elective
C-section

OBSTETRIC CHOLESTASIS
History Symptoms: itch (palms & Investigations
soles), fatigue, poor - Fasting bile acid (>10)
appetite, mild jaundice, pale - LFT: AST/ALT weekly
stools, dark urine. No rash TRO other causes: virology screen, liver
Ask RF autoimmune screen, liver USS
- Multiple pregnancy
- Past hx DDx: pre-eclampsia, acute fatty liver of pregnancy
- Fx Risks: stillbirth, spontaneous preterm birth,
- IVF increased fetal distress and PPH
- Advanced maternal
age Management
- History of Ursodeoxycholic acid improves pruritus and
gallstones/hepC liver function
Rifampicin, antihistamines, moisturizes
Vit K 10mg PO daily from 36 weeks
Exam Jaundice
Piriton or aqueous menthol cream if itch severe
Induce labour at 37 weeks
 GESTATIONAL DIABETES
Risk Factors 1st degree relative with diabetes
Advanced maternal age >40 years
Ethinicity: asian, black caribbean, middle eastern
Maternal obesity BMI >30
History of GDM
History of macrosomia (>4.5kg)
Polyhydramnios / macrosomia in existing pregnancy
Unexplained stillbirth
PCOS, thyroid disease

Ask any HTN

Risks Fetal
Antepartum
o Macrosomia / BW is increased
o Polyhydramnios from increased urine output due to hyperinsulinemia
Intrapartum
o Preterm labour
o Dystocia + birth trauma
Postpartum
o Stillbirth
o Fetal lung maturity is less
o RDS
o Hypoglycemia
o Polycythemia
Maternal
Antenatal
o Hypoglycemia; insulin requirement is increased
o HTN, pre-eclampsia
o Infection, ketoacidosis
Intrapartum
o Induction of labour
o Operative vaginal delivery
o CS
Postpartum: T2DM
Management Booking visit -- If RF present, do 2hr 75/100g OGTT at 24-28 weeks
Patient education
Diet and lifestyle change
Blood glucose monitoring 7x glucometer daily
Insulin +/- Metformin
2 weekly monitoring: BP, urinalysis, weight, biometry, US anatomy scan
Steroids if preterm delivery risk
Post-partum: breastfeeding, feed within 1hr; OGTT 6 weeks
 MULTIPLE PREGNANCY
History - Spontaneous conception vs
assisted reproduction
(clomiphene, superovulation
with IUI, IVF, ICSI --- how
many embryos)
- Shared placenta?
- Diagnosis when and how
ultrasound diagnosis <14
weeks most accurate
- Complications to date
threatened miscarriage,
anomaly scan, TTTS, IUGR
- Maternal medical history
- Folic acid
- Serial US IUGR, liquor
volume (will get US every 2
weeks)
- What is plan for delivery?
Exam Lie and presentation
>2 poles
SFH increased
Maternal risks
- Increased symptoms
- risk of miscarriage
- Increase CS
- PET 5x
- Gestational diabetes
- Placental abruption
- APH, PPH, PPROM
- Anaemia
Fetal Risks
- Perinatal mortality 5x
- Low birth weight/IUGR
- Preterm delivery
- Congenital / chromosomal
abnormalities
- Cerebral palsy 4x
- Twin-to-twin transfusion syndrome
- Inter-twin growth discordance
- >18% difference in BW
- Co-twin death
- Malpresentation
- Cord entanglement
Aim delivery at 37-38 (DCDA), 34-37
(MCDA), 32 (MCMA)

Nausea and Vomiting

History Causes
- Food and fluid intake - Hyperemesis gravidarum (diagnosis of exclusion)
- Weight loss (>5% pre- - Morning sickness
pregnancy weight) - GI GE, reflux, appendicitis, cholecystitis, pancreatitis
- Associated symptoms - Neuro: meningitis
Retrosternal - Obstetric: molar pregnancy
burning pain - Endocrine hyperT
Abdominal Complications
pain - Dehydration
Neuro, - Electrolyte disturbances hyponatremia
endocrine - Mallory-weiss tears
- SGA, low BW
Management
- TRO secondary causes
- IV fluids, correct hypoNa, hypoK
- Thiamine?
- Antihistamine (cyclizine) or corticosteroids (2nd line)
 Abdominal Pain
History SOCRATES Causes
Analgesics required - Miscarriage (crampy), ectopic (sharp)
a/w urinary or obwel - Onset of labour
PV loss: Vaginal bleeding or - Placental abruption, placenta percreta
discharge, show - Chorioamnionitis (preterm rupture?)
ROM - Acute pyelonephritis, cystitis
Uterine activity Contraction? - HELLPP, PET
Fever - Uterine rupture
Urinary symptoms - Acute fatty liver of pregnancy
Nausea, vomiting - Round ligament pain
FM? - Symphysis pubis dysfunction
Past medical history - Fibroids red degeneration
Exam IMEWS - Arterial dissection, rupture of aneurysm
Site of pain local / general - Non-pregnancy: GERD, cholecystitis,
Presence of hepatitis, pancreatitis, pneumonia,
rebound/guarding, bowel bowel obstruction, ulcer, appendicitis,
sounds (ileus/obstruction) nephrolithiasis, diverticulitis
Uterine/abdo tenderness - Gynae: ovarian torsion, ruptured cyst,
(chorio?)
Uterine irritability (palpation,
CTG) -?labour
Speculum cervical dilatation,
liquor, blood, abnormal
discharge
Urinalysis
US >28 weks
FH?

Booking visit

1) FBC anaemia, elevated WCC, thrombocytopenia

2) Haemoglobinopathy screen sickle cell, beta thalassemia
3) Group and antibodies Anti-D, E, C, Kell antibodies
4) Viral serology HIV (viral load), Hep B (HBsAg, HBeAg), Hep C (HCV Ab, HCV RNA), syphilis,
rubella IgG, VZV IgG
5) BP, urinalysis
6) US dating, ordering chorio/amnio, viable
- Classify into high risk or low risk

Indications
Maternal factors
- 2 previous LSCS or 1 previous
classical CS
- Previous full-thickness non-
transverse incision through
the myometrium
- Pre-eclampsia, chronic heart
or lung disease
- Placenta praevia
- APH/IPH
- Abnormal labour progress
- Cord prolapse
Fetal Factors
- Malpresentation
breech/transverse
- Multiple pregnancy
- IUGR, fetal anomaly
- Fetal distress
C-section
Complications
Maternal
- Haemorrhage - uterine atony, placenta accreta,
genital tract trauma
- Need for blood transfusion
- Infection of the uterus or wound
- Visceral damage - urinary tract, bowel
- VTE
- Urinary infection
- Mastitis
- Perineal infection
- Incidence of placenta previa
Fetal
- Fetal respiratory morbidity
- Fetal lacerations
- Bonding BF
Long term
- Increased risk of CS
- Risk of uterine rupture, placenta previa and
peripartum hysterectomy
- Increased risk of future stillbirth
- Risk of infertility?

CHORIOAMNIONITIS
History PPROM/PROM RF
Generalised abdominal pain o Prolonged rupture of membranes
 Abnormal offensive discharge
color, smell, take swabs
Fever and general malaise +/-
chills
Nausea and vomiting, diarrhoea
Recent amniocentesis, CVS
Previous investigation results
Exam flushed, tachycardic, pyrexial
hypotension in severe infection
tender uterus
offensive discharge or liquor on
speculum
cervical dilatation
fetal tachy
Non-reassuring CTG
Presentation
o Prolonged duration of labor
o Multiple vaginal exams
o Young age
o Lower socio-economic group
o Nullips -- longer labors
o Pre-existing bacterial vaginosis
Investigations
- Raised WCC, CRP (WCC may be low if
septic)
- U/E, LFT, Clotting (DIC in severe)
- Blood cultures if pyrexial
- HVS, rectal swab +/- endocervical swab
- MSU
Management
- C+S bloods, swabs, MSU
- Broad spectrum IV antibiotics =
benzylpen + gent + metro
- Expedite delivery usu. CS
- Inform anaesthetics, neonatal

UTI Asymptomatic Bacteriuria Acute uncomplicated Pyelonephritis

UTI/cystitis
Cause E.Coli, proteus, klebsiella, GBS, E.coli, proteus,
enterococcus klebsiella
History NIL symptoms Low back pain loin abdo pain, fever
Exam General flu-like symptoms rigors, vomitting
Pyrexia, tachy, tender
renal angle
Ix MSU >100000/ml, single MSU >100000/ml, single MSU, FBC, CRP, U/E,
pathogen pathogen cultures, Renal tract
cloudy, WBC, protein, cloudy, WBC, protein, nitrates, USS (non-urgent),
nitrates, blood blood

Management Antibiotics 7-days treatment 14 days

Repeat MSU following
treatment
Consider suppressive
therapy if 2 or more
episodes
Cephradine 250-500mg 6
hourly PO / cefalexin
Or Co-amoxiclav 375-625mg 8
hourly PO
Or trimethoprim 200mg 12
hourly PO (not 1st trimester)
Or nitrofurantoin 50mg 6
hourly PO (T1 T2 ok,not near
term, can cause neonatal
haemolysis) --- only useful for
cystitis and must be afrebrile
Cefotaxime 1g 8 hourly
IV; +/- gentamicin,
switch to oral based on
C&S when 24/48h
apyrexia
IV fluids,
thromboprophylaxis if
immobile
Complications: preterm
labor, sepsis

Large for gestational age

Ddx
 - Macrosomia
- Polyhydramnios
- Wrong date
- Multiple gestation
POLYHYDRAMNIOS = >95th centile
Causes
o Idiopathic
o Maternal: DM polyuria
o Fetal
Twins any Twin Twin Transfusion?
Impaired swallow -- esophageal atresia, anencephaly
Duodenal atresia
Clinical
o Maternal discomfort
o Large for dates, increased SFH
o Taut uterus
o Fetal parts difficult to palpate
Complications
o PROM
o Preterm labor
o Unstable lie
o Mal presentation
o PPH / uterine atony
Management
o ? Fetal anomaly --> US
o ? DM --> GTT
o If <34 weeks and severe, amnioreduction may be used to reduce fetal urine output
o Assess cervical length, consider cerclage if <35mm