Phase 3a Louise & Alys The Peer Teaching Society is not liable for false or misleading information…

Antenatal Screening Hyperemesis Miscarriage Ectopic Pregnancy Molar Pregnancy Pre - eclampsia The Peer Teaching Society is not liable for false or misleading information… Aims

The Peer Teaching Society is not liable for false or misleading information… Antenatal Screening

Detect Disease in the mother Prevent or detect and manage maternal complications Prevent or detect foetal complications Detect congenital foetal problems if requested by patient The Peer Teaching Society is not liable for false or misleading information… Q – Why do we screen in pregnancy?

BP BMI FBC Serum antibodies (anti-d) BM Syphilis Rubella immunity HIV Hep B and C Urine dip The Peer Teaching Society is not liable for false or misleading information… Q- What investigations are done at the booking visit?

Those with an at risk Hx – Hx of GDM – 1 st degree relative with diabetes – Previous unexplained stillbirth – Previous macrosomic infant (BW >4kg) – Maternal BMI >30 – Repeated episodes of glycosuria – Maternal age >35yrs – PCOS The Peer Teaching Society is not liable for false or misleading information… Q- Who should be screened for Gestational diabetes?

Presence of foetus and no. of foetuses Heartbeat Crown Rump Length Foetal nuchal translucency Check ovaries The Peer Teaching Society is not liable for false or misleading information… Q - What do they look for at first scan?

Confirm viability of foetus Foetal measurements: Foetal head size, abdominal circumference, biparietal diameter, femur length Detect structural abnormalities – e.g. anencephaly, spina bifida Internal structure abnormalities – e.g. heart disease, diaphragmatic hernia Amniotic fluid volume The Peer Teaching Society is not liable for false or misleading information… Q -What do they look for at the 2 nd scan?

Combined test (11-14 wks): Nuchal translucency + PAPP-A + β-HCG Quadruple test (14-20wks): – AFP – Inhibin A – Oestrodiol – β-HCG The Peer Teaching Society is not liable for false or misleading information… Q- What are the types of Down’s screening?

Amniocentesis: – Can detect Neural tube defects and chromosomal disorders – Takes 3 weeks for karyotyping – 1% foetal loss rate Chorionic Villous Sampling: – Can be used up to 20 wks – Doesn’t detect NTD – Placental sample – Quicker result (2 days for karyotyping) – 4% foetal loss rate The Peer Teaching Society is not liable for false or misleading information… Amniocentesis and CVS

The Peer Teaching Society is not liable for false or misleading information…

Persistent pregnancy related vomiting associated with weight loss of >5% of body mass, dehydrations and ketosis. Begins between 4-10 wks, ends before 20wks The Peer Teaching Society is not liable for false or misleading information… Hyperemesis Gravidarum

Idiopathic Multiparous Multiple pregnancy Hyatidiform mole Hx of Hyperemesis Gravidarum H. pylori infection The Peer Teaching Society is not liable for false or misleading information… Q – what are predisposing factors of Hyperemesis Gravidarum?

Dehydration – Tachycardia – Hypotension Electrolyte imbalance – HYPOCHLORAEMIC ALKALOSIS Thiamine deficiency The Peer Teaching Society is not liable for false or misleading information… Q - What are the complications?

Exclude other causes of vomiting Urine Dip for ketones, blood and proteins and send for cultures FBC U&Es LFTs TFTs Blood Gasses USS The Peer Teaching Society is not liable for false or misleading information… Investigations

IV fluids – correct hypovolaemia and electrolte imbalance Antiemetics e.g. cyclizine and metoclopramide THIAMINE Thromboprophylaxis – compression stockings and consider LMWH The Peer Teaching Society is not liable for false or misleading information… Management

Pregnancy loss <24 weeks gestation 15% pregnancies The Peer Teaching Society is not liable for false or misleading information… MISCARRIAGE

Most are idiopathic Chromosomal abnormality PCOS Advanced maternal age Maternal lifestyle – Smoking, obesisty, alcohol, caffeine, cocaine, cannabis, stress Uterine abnormalities Cervical incompetence Infection Antiphospholipid syndrome Thrombophylic defects The Peer Teaching Society is not liable for false or misleading information… Q – What are some causes of miscarriage?

Threatened miscarriage Inevitable miscarriage Incomplete miscarriage Complete miscarriage Missed miscarriage Septic miscarriage The Peer Teaching Society is not liable for false or misleading information… Types of Miscarriage

Threatened miscarriage – Bleeding, uterus enlarged, foetus alive, os closed – 25% go on to miscarry Inevitable miscarriage – Heavier bleeding, os open, miscarriage will happen Incomplete miscarriage – Pain develops, os open, some parts passed, some retained Complete miscarriage – All foetal tissue passed, uterus not enlarged, os closed, bleeding subsides Missed miscarriage – Empty gestational sac on USS, uterus smaller than expected and os closed, can be asymptomic Septic miscarriage – Contents of uterus are infected, shock can develop The Peer Teaching Society is not liable for false or misleading information…

Urine dip – pregnancy test USS FBC and Rhesus group Expectant management Medical management – MISOPROSTOL Surgical management – ERPC The Peer Teaching Society is not liable for false or misleading information… Management

Any pregnancy occuring outside of the uterine cavity Most common site is the Fallopian tube 1% of all pregnancies The Peer Teaching Society is not liable for false or misleading information… Ectopic Pregnancy

Idiopathic Hx of ectopics Hx of chlamydia PID Subfertility Pregnancy that happens despite the presence of an IUD The Peer Teaching Society is not liable for false or misleading information… Q – What are some predisposing factors?

Amenorrhoea of 4-10 wks Lower abdo pain followed by dark vaginal bleeding (+/- clots) Pain is initially colicky and then constant Can mimic appendicitis Subdiaphragmatic irritation causes referred shoulder-tip pain Collapse (<25%) Signs on examination: – Signs of shock – hypotension and tachycardia – Peritonism – abdo distension, guarding, rebound tenderness – Cervical excitation – Adnexal tenderness The Peer Teaching Society is not liable for false or misleading information… Q – What is the clinical presentation?

Diagnosis: – Urine pregnancy test + USS – Serum hCG – FBC – Cross match blood – Give patient anti-D if Rh -ve Management: – Medical – Methotrexate – Surgical – Salpingotomy or salpingectomy The Peer Teaching Society is not liable for false or misleading information… Diagnosis and management

Abnormality of early trophoblast Due to a developmental anomaly of the placental tissue with the formation of a mass of oedematous and avascular villi The placenta is replaced by grape-like vesicles (the hyatidiform mole) Arise from fertilazation by 2 sperm Benign moles remain in the uterine cavity 16% of benign moles invade the myometrium 2.5% leading malignant choriocarcinoma The Peer Teaching Society is not liable for false or misleading information… Hyatidiform Mole

Locally in the vagina Through blood borne mets to the lungs The Peer Teaching Society is not liable for false or misleading information… Q – Where can choriocarcinoma spread to?

Complete mole – diploid (XX) entirely paternal – sperm fertilizes an empty oocyte Partial mole – triploid (XXY) variable evidence of foetus. The Peer Teaching Society is not liable for false or misleading information… Q – What is a complete mole and what is a partial mole?

Bleeding in 1 st half of pregnancy Severe vomitting Symptoms of pre-eclampsia Unexplained anaemia No pain May pass grape-like villus May be detected in routine USS The Peer Teaching Society is not liable for false or misleading information… Q - How does it present?

USS – SNOW STORM APPEARANCE if a complete mole Increased HCG in blood/urine Diagnosis is confirmed histologically The Peer Teaching Society is not liable for false or misleading information… Q – How do we diagnose?

Once diagnosis established: – Terminate pregnancy (ERPC) – Replace blood loss Follow up – repeat hCG at regular intervals for at least 6 months Avoid pregnancy and taking COCP until HCG normal The Peer Teaching Society is not liable for false or misleading information… Management

Hypertension with significant proteinuria after 20wks gestation. Hypertension = BP >140/90 Significant proteinuria = 300mg/24hrs Complicates up to 10% of pregnancies The Peer Teaching Society is not liable for false or misleading information… Pre-eclampsia

Nulliparity Prev. Hx of pre eclampsia Multiple pregnancy Chronic hypertension DM BMI > 35 Age over 40 CKD Family history If high risk – give low dose aspirin prophylaxis The Peer Teaching Society is not liable for false or misleading information… Q – what are the risk factors?

Headache Visual disturbances Vomiting Oedema of face/hands/feet Epigastric pain Signs: Clonus Hyperreflexia Papilloedema hypertension The Peer Teaching Society is not liable for false or misleading information… Q – what are the clinical Features?

Maternal – Prothrombotic – low platelets – can lead to DIC – HELLP (Haemolysis Elevated Liver enzymes Low Platelets) – Hepatic failure – Renal failure – CNS – eclampsia, cerebral haemorrhage The Peer Teaching Society is not liable for false or misleading information… Q – What are the potential complications?

Foetal – Oligohydraminos – IUGR – Placental abruption – Prematurity – Foetal death The Peer Teaching Society is not liable for false or misleading information…

Aim to prevent eclampsia and further complications. CONTROL BP – Labetolol/nifedipine/ methyldopa SEIZURE PREVENTION – Magnesium Sulphate STEROIDS – give if <34 wks to promote foetal lung development Fluid management DELIVERY IS THE ONLY CURE! – Before 34 wks consider C-section – Induce labour when safe! The Peer Teaching Society is not liable for false or misleading information… Management

The Peer Teaching Society is not liable for false or misleading information… Any Questions?