A QUICK TOUR OF INFERTILITY BLEEDING IN PREGNANCY REDUCED FETAL MOVEMENT AND POST DATES Dr Sonia Asif

I can’t get pregnant-Background 1 in 7 couples present with infertility Defined as failure to conceive after 2 years of regular unprotected sexual intercourse 84 % of couples will conceive after 1 year Half of the remaining 16% will conceive after 2 years (92%) Offer clinical investigation (ovulation test/semen analysis) after 1 year in those who are particularly concerned Offer early investigations to if there is a history of:- PID Oligoamenorrhoea Endometriosis female age>35 Female fertility naturally declines with age and this a significant factor to consider when thinking about offering investigations 94% of fertile women over 35 77% of fertile women over 38 will conceive after 3 years)

Initial Assessment Mr and Mrs White come to see you in the clinic concerned that they have not conceived despite trying for 3 years. ?Female history ?Male history

Initial Assessment Female history Obstetric History-previous pregnancies and outcomes Gynaecological history-cycle length/regularity(If irregular ask about symptoms of PCOS) Sexual history-dyspareunia /postcoital bleeding/past STI Contraception history-when stopped and what they were using? Surgical history-previous abdominal/pelvic surgery Smear history Rubella status Smoking/Alcohol/BMI Drug history-NSAIDS/Thyroxine/Antidepressants can cause anovulation Male history Past conception with other partners Impotence/Ejaculation Issue History of diabetes/hypertension History of trauma to the genital area/past STI Drug history-Cimetidine/anabolic steroids/Sulphasalazine can impair semen quality Betablockers can cause impotence Frequency of sexual intercourse-Should ideally be 2-3 times a week Ovulation kits are not recommended as they cause undue stress

Lifestyle Advice

Lifestyle Advice Reassure regarding natural conception (2 year rule) Normalise BMI(19-30)-Refer to dietitician/exercise programmes Stop Smoking/recreational drugs(refer to smoking cessation) Reduce Alcohol(1-2 units,1-2 times a week) Start taking folic acid (need to take for 3 months preconceptually) Give rubella vaccination if not immune Advise loose fitting underwear for the male partner Minimise Stress-Refer for counselling if needed Refer to support group if appropriate

Initial Investigations Female Male

Initial Investigations-Primary Care Female Day 2-5 FSH/LH (below 10) Mid luteal progesterone-Day 21 (above 30-50) If oligoamennorrhoea-Induce a withdrawal bleed with provera and then time tests Prolactin Rubella status Recent Smear Chlamydia Screening Male Semen Analysis If abnormal repeat in 3 months

Further Investigations-Secondary Care Female Check tubal patency Hysterosalpingogram if no history of PID/Endometriosis/Ectopic pregnancy Laparoscopy and Dye test if tubal or pelvic pathology suspected Male If no very low concentration/no sperm:- FSH/LH/Testosterone CF screening/Karyotype

Semen Analysis-WHO classification Factor Normal Range Volume 2.0mls or more Liquefaction time Within 60 minutes pH 7.2 or more Total Sperm Number >40million per ejaculate Sperm Concentration >20 million per ml Motility (grade a –rapidly motile and b-slow motility) within 60 minutes of ejaculation >50% >25% rapidly motile Morphology 15% Vitality 75% WBC <1 million/ml

Classifying Infertility and treatments Type of Infertility Incidence Treatments Ovulation 21% Lifestyle Advice Clomiphene and Tamoxifen for 12 months Add in metformin if PCOS Ovarian Drilling Male 20% IUI/IVF/ICSI Sperm Recovery/Donation Tubal 14% Tubal Surgery/IVF Unexplained 8-28% Expectant Empirical Clomiphene IUI IVF Uterine (Septum/polyps/ fibroids) 10-15% Surgically remove cause Endometriosis 20-30% Surgical ablation/adhesiolysis IUI/IVF

NHS Funded or not? Meets the definition of Infertility Couples in a stable relationship for at least 2 years No previous children for either partner Female Age 23-40 Male Age<55 BMI 19-30 Non Smokers Welfare of the child

BLEEDING IN PREGNANCY ANTEPARTUM HEAMORRHAGE Antepartum haemorrhage is defined as bleeding from the genital tract from 24 weeks to the delivery of the fetus (>10mls is significant) It affects 6% of pregnancies and can lead to significant maternal and fetal morbidity Although bleeding can occur from anywhere in the genital tract, the acute and life threatening causes include placenta praevia and placental abruption 13

I’M PREGNANT AND I’M BLEEDING Beyonce Knowles comes to the antenatal assessment centre .She is in her second pregnancy and his 33 weeks pregnant. When she went to the toilet to pass urine she noticed fresh red bleeding on her underwear. Her fetal movements are normal. What do you need to ask in her history? What could be the causes? Initial management?

PLACENTA PRAEVIA This is classified as a placenta lying wholly or partly in the lower uterine segment There are 4 type depending on the coverage of the cervix Complicates 0.5% of pregnancies at term Usually diagnosed on detailed USS with a rescan arranged for 32-34 weeks Presents with painless bleeding which can lead to placental abruption On abdominal palpation can lead to a high head and malpresentations (breech,transverse lie) Vaginal delivery is only possible if the placental edge is >2cm from the cervical os 15

PLACENTAL ABRUPTION This is the premature separation of the placenta from the uterine wall Presents with painful bleeding Can be concealed or revealed Usually leads to fetal compromise Diagnosis is made clinically with a tender,tense uterus and delivery should be immediate by caesarean section Risk factors:- smoking, abdominal truama, pre- eclampsia, previous abruption,crack cocaine use 16

MANAGEMENT OF HEAVY BLEEDING IN PREGNANCY CALL FOR HELP ABC APPROACH RESUSCITATE IF MATERNAL COMPROMISE AIM FOR RAPID DELIVERY ALERT BLOOD BANK THE AIM IS TO PREVENT MORTALITY/ MORBIDITY AND THE PROGRESSION TO DISSEMINATED INTRAVASCULAR COAGULOPATHY 17

Reduced Fetal Movements One of the most common cause of maternal anxiety and assessment centre consultations 1st episode-CTG and reassure 2nd episode-CTG and Growth USS 3rd episode or more Identify risk factors and individualise care If low risk, reassure and maybe do growth USS If high risk, monitor more closely,2 weekly growth USS, twice weekly CTG’s If post dates-offer IOL

I’ve gone over my dates Around 1% of pregnancies go over their dates A normal placenta has a shelf life of 40 weeks and 16 days After this the rate of still birth increases You are the doctor in clinic and are about to see Victoria Beckham who is a G1P0 lady who is term+6. How will you counsel her? What are her options